drtfyur  Dolney  Stougl^ton. 


COLLEGE  OF   OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS   •  LOS  ANGELES,  CALIFORNIA 


PRESS  NOTICES  OF  THE  FIRST  EDITION. 


"  The  work  can  be  earnestly  recommended  as  a  faithful  exponent  of  American  gyne- 
cology,  conceived  in  a  spirit  of  moderation  and  conservatism." — Medical  Record, 
New  York. 

"  While  written  in  a  concise  way,  it  is  exceedingly  full,  and  covers  the  whole  ground 
of  gynecology.— Boston  Medical  and  Surgical  Journal. 

"  The  chapter  on  the  Anatomy  of  the  Female  Pelvic  Organs  cannot  be  too  highly 
commended.  .  .  .  The  author  shows  a  wide  knowledge  of  therapeutics  and  a  com- 
mendable wealth  of  resource.  .  .  .  The  author's  descriptions  of  operations  are  particu- 
larly lucid." — Annals  of  Surgery. 

"  We  think  it  one  of  the  few  really  good  books  on  gynecology  for  the  general 
practitioner." — New  York  Medical  Journal. 

"  It  is  in  every  sense  a  safe  text-book  to  place  in  the  hands  of  the  student  and  gen- 
eral practitioner;  while  the  style  is  so  lucid,  concise,  and  forcible  that  no  one  can 
misunderstand  a  single  statement." — American  Journal  of  the  Medical  Sciences. 

"  A  useful  work.  A  capital  index  makes  consultation  easy." — Edinburgh  Med- 
ical Journal. 

"  The  chapter  on  Diseases  of  the  Fallopian  Tubes  is  up  to  date,  complete,  and 
instructive,  as  are  also  the  chapters  on  Uterine  Fibroids,  Diseases  of  the  Ovaries,  and 
Peri-uterine  Inflammation." — American  Medico-Surgical  Bulletin. 

"  The  surgeon  will  find  much  to  interest  him,  and  he  will  turn  to  its  pages  for  hurried 
consultation  much  oftener  than  to  some  of  the  more  elaborate  '  text-books '  and  '  sys- 
tems.' " — Journal  of  the  American  Medical  Association. 

"  The  special  merits  of  this  work  are  that  it  is  a  book  of  moderate  size,  and  hence 
comparatively  inexpensive ;  that  it  is  thoroughly  modern ;  that  the  subjects  are  so  well 
tabulated  and  indexed  that  reference  is  easy ;  that  the  author's  style  is  singularly  con- 
cise and  clear.  .  .  .  The  illustrations  are  copious  and  admirable." — Therapeutic 
Gazette. 

"  One  is  struck  with  its  clearness  and  practical  value." — Annals  of  Gynecology 
and  Pediatrics. 

"  This  work  is  in  our  opinion  the  most  practical  text-book  on  gynecology  (from 
the  standpoint  of  the  general  practitioner)  thus  far  published." — Hahnemannian 
Monthly. 

"  We  do  not  know  of  any  work  which  is  so  replete  with  technique  and  fair  detailed 
instructions." — Chicago  Clinical  Review. 


PROFESSIONAL    COMMENTS. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published 
in  the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound 
learning  and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this 
book  in  a  most  attractive  and  instructive  form.  Young  practitioners,  to  whom  expe- 
rienced consultants  may  not  be  available,  will  find  in  this  book  invaluable  counsel  and 
help." — THAD.  A.  REAMY,  M.  D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical 
College  of  Ohio;  Gynecologist  to  the  Good  Samaritan  and  Cincinnati  Hospitals. 

"  I  can  heartily  recommend  it  to  students  and  practitioners.  It  is  concise,  compre- 
hensive, and  consistent.  I  have  in  my  library  almost  every  recent  author  on  this  sub- 
ject, and  among  them  all  I  find  none  better  fitted  for  a  text-book  than  the  volume  you 
have  just  published.  I  do  not  see  how  it  can  fail  of  being  very  popular." — JOHN  W. 
STREETER,  Professor  of  Gynecology,  Chicago  Homeopathic  Medical  College. 


A  TEXT-BOOK 


OF  THE 


DISEASES  OF  WOMEN. 


BY 

HENRY  J.  GARRIGUES,  A.  M.,  M.  D., 


Professor  of  Gynecology  and  Obstetrics  in  the  New  York  School  of  Clinical  Medicine ;  Gyne- 
cologist to  St.  Mark's  Hospital  in  New  York  City ;  Gynecologist  to  the  German  Dispen- 
sary in  the  City  of  New  York ;  Consulting  Obstetric  Surgeon  to  the  New  York 
Maternity  Hospital ;  Ex-President  of  the  German  Medical  Society  of  the  City 
of  New  York ;  Fellow  of  the  American  Gynecological  Society  ;  Fellow 
of  the  New  York  Academy  of  Medicine ;  Member  of  the  Society 
for  Medical  Progress,  of  the  Eastern  Medical  Society, 
of  the  New  York  County  Medical  Society,  etc. 


CONTAINING  THREE  HUNDRED  AND  THIRTY-FIVE  ENGRAVINGS 
AND  COLORED  PLATES. 


SECOND  EDITION,  THOROUGHLY  REVISED. 


PHILADELPHIA : 

W.    B.    SAUNDERS, 

925  WALNUT  STREET. 

1897. 


\)J?l°0 

&  p.<-l 1 

1*17 


Copyright,  1897,  by 
W.     B.     SAUNDERS. 


ELECTHOTYPED  BY 
WC8TCOTT  *  THOMSON,  PHILAOA. 


PRESS  OF      . 
W.   B.   SAUNDERS.   PHItAOA. 


TO 


ABRAHAM   JACOBI,  M.  D., 


PROFESSOR    OF    DISEASES    OF    CHILDREN    IN    THE    NEW    YORK    COLLEGE    OF    PHYSICIANS    AND 

SURGEONS  ;    EX-PRESIDENT  OF  THE  MEDICAL  SOCIETY  OF  THE    STATE  OF  NEW  YORK  ; 

EX-PRESIDENT  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE,   ETC.,  ETC., 

THIS   WORK 
IS    RESPECTFULLY    INSCRIBED 

BY 

THE    AUTHOR. 


PREFACE. 


THE  term  "  Diseases  of  Women  "  is  understood  to  designate  the 
affections  of  the  genital  organs  in  the  female  sex  other  than  those 
connected  with  pregnancy,  childbirth,  and  the  puerperal  state.  That 
branch  of  medical  science  and  art  that  is  devoted  to  this  subject  is 
called  Gynecology. 

In  writing  this  book  I  have  first  had  in  view  the  large  class  of 
physicians  who  have  not  had  the  advantage  of  hospital  training, 
and  who  go  to  a  post-graduate  school  in  order  to  learn  gynecology. 
They  can  only  stay  a  short  time,  and  they  want  a  full  but  concise 
exposition,  up  to  date,  of  the  nature  and  treatment  of  the  diseases 
peculiar  to  women. 

Secondly,  I  have  tried  to  satisfy  the  requirements  of  that  much 
larger  class  who  would  like  to  go  to  such  an  establishment,  but  who 
find  it  impossible  to  leave  their  practice.  They  are  busy  men,  who 
have  to  keep  abreast  of  recent  progress  as  best  they  can  in  all 
branches  of  a  general  practitioner's  work.  They  want  information 
about  the  present  state  of  gynecology,  but  cannot  find  time  to  study 
large  works. 

If  in  large  cities  it  is  better  for  the  general  practitioner,  as  well 
as  for  his  patient,  to  leave  the  treatment  of  most  gynecological 
cases  to  those  who  have  special  experience  and  skill  in  this  line, 
the  same  does  not  always  hold  good  in  country  practice.  The 
long  distances  in  this  immense  country  make  it  very  difficult,  and 
often  impossible,  to  send  patients  to  places  where  they  can  be  treated 
by  specialists.  American  physicians  are  enterprising,  and  some 
men  practicing  in  a  village  have  achieved  world-wide  renown,  and 
become  the  leaders  of  their  city  confreres. 

Finally,  I  think  the  book  will  be  found  useful  by  undergradu- 
ates studying  in  medical  colleges.  They  will  probably  at  that  stage 


30987 


2  PREFACE. 

of  their  development  skip  many  details  about  operations,  which  they 
will  be  glad  to  take  up  later,  when  the  responsibility  of  a  medical 
practitioner  lies  heavy  on  their  shoulders.  The  division  into  a  gen- 
eral and  a  special  part  will  presumably  be  useful  for  the  beginner, 
and  he  will  hardly  care  to  pay  much  attention  to  what  has  been 
placed  in  notes  under  the  text. 

This  being  a  book  for  General  Practitioners  and  Students,  I 
have  omitted  all  reference  to  the  historical  development  by  which 
gynecology  has  attained  its  present  stage,  as  well  as  all  reports  of 
special  cases. 

The  limits  and  the  nature  of  the  work  have  not  allowed  me  to 
speak  of  all  methods  of  treating  every  disease,  but  I  have  striven 
to  give  a  clear  and  succinct  description  of  the  best  modes  of  treat- 
ment ;  and  the  reader  will  in  this  book  find  many  details  which  he 
would  look  for  in  vain  in  larger  works. 

My  aim  has  been  to  write  a  practical  work.  The  reader's  time 
is  not  taken  up  by  theoretical  discussions,  and  the  pathology  has 
been  treated  very  briefly.  On  the  other  hand,  I  have  tried  to  help 
the  reader  to  make  a  diagnosis,  and  to  teach  him  how  to  treat  the 
different  diseases.  In  this  respect  I  have  gone  into  minute  details 
affording  manifold  information  about  points  which  practitioners  who 
live  in  large  cities  learn  from  one  another  or  by  visits  to  the  shops 
of  the  instrument-makers. 

I  have  treated  so  discursively  of  the  anatomy  of  the  female  geni- 
tals because  this  subject,  to  a  great  extent,  has  been  worked  up  by 
the  gynecologists  themselves,  and  is  not  as  yet  described  satisfactorily 
in  the  text-books  of  anatomy,  but  only  in  large  works  of  an  encyclo- 
pedic character  or  in  articles  in  journals  to  which  many  have  not 
access. 

I  expect  to  be  criticised  for  having  devoted  special  chapters  to 
Hemorrhage  and  Leucorrhea.  I  know  well  that  they  are  not  dis- 
eases ;  but  they  are  symptoms  that  play  so  great  a  part  in  the  diseases 
of  women,  and  so  often  require  symptomatic  treatment,  that  I  take 
it  to  be  in  the  interest  of  the  general  practitioner  to  treat  them  sep- 
arately; and  besides,  by  so  doing  infinite  repetitions  are  avoided. 

This  being  a  text-book  for  beginners  and  a  manual  for  general 
practitioners,  names  of  authors  have  been  omitted  as  much  as  possi- 
ble from  the  text,  except  when  it  was  necessary  in  order  to  designate 


PREFACE.  3 

different  methods  of  operations.  In  making  use  of  the  work  of 
American  authors  I  have,  however,  given  them  credit  for  it  in 
foot-notes,  and  I  trust  that  it  will  be  found  that  a  large  amount 
of  information  of  this  kind  has  been  embodied  in  the  text. 

In  indicating  the  treatment  of  the  various  affections,  I  mention 
always  the  simpler  and  innocuous  means  before  the  more  compli- 
cated and  dangerous,  medical  and  electrical  treatment  being  accorded 
precedence  over  surgical. 

Throughout  the  work  a  chief  object  has  been  to  give  modes  of 
treatment  as  they  are  practiced  in  America,  by  which  I  hope  that 
it  will  be  found  more  useful  for  American  students  and  practitioners 
than  the  works  written  by  or  translated  from  foreign  authors. 

The  Illustrations  form  a  complete  atlas  of  the  embryology  and 
anatomy  of  the  female  genitalia,  and  represent  numerous  operations 
and  pathological  conditions.  Many  come  from  my  own  operations, 
dissections,  and  microscopical  examinations. 

155  LEXINGTON  AVENUE,  New  York,  January,  1894. 


PREFACE  TO  THE  SECOND  EDITION. 


THE  first  edition  of  this  work  met  with  a  most  appreciative  recep- 
tion by  the  medical  press  and  profession  both  in  this  country  and 
abroad,  and  a  large  number  of  colleges  in  the  United  States  and 
Canada  have  recommended  the  book  to  their  students. 

If  I  have  enjoyed  the  praise  bestowed  upon  the  book,  I  have  paid 
no  less  attention  to  just  criticisms,  and  have  embraced  the  oppor- 
tunity afforded  by  this  revision  to  bring  the  work  up  to  date. 

In  this  second  edition  old-fashioned  patterns  of  instruments  have 
been  replaced  by  new  ones,  defective  original  illustrations  have  been 
artistically  redrawn,  and  many  new  figures  have  been  added. 

Aseptic  surgery,  which  was  in  its  infancy  when  the  first  edition 
was  written,  has  been  more  carefully  considered,  still  retaining  its 
forerunner,  antisepsis,  which  in  many  respects,  by  the  nature  of 
things,  is  indispensable,  and  often  is  all  that  can  be  obtained  in 
private  practice. 

Parts  of  the  text  and  some  of  the  illustrations  that  seemed  anti- 
quated or  of  minor  importance  have  been  omitted,  and  considerable 
new  material  has  been  incorporated. 

The  whole  surgical  treatment  of  Uterine  Fibroid  and  Cancer  has 
been  rewritten  and  much  simplified. 

Vaginal  Section  has  been  placed  on  equal  terms  with  Abdominal 
Section. 

Descriptions  of  the  chief  methods  employed  in  Intestinal  Sur- 
gery have  been  added  to  the  Appendix. 

I  have  more  extensively  expressed  my  own  opinion  on  the  com- 
parative value  of  different  methods  of  treatment,  but  the  applicability 
of  these  methods  to  particular  cases  depends  upon  circumstances  of 
which  only  the  attending  physician  or  surgeon  is  judge. 

716  LEXINGTON  AVENUE. 
4 


CONTENTS. 


GENERAL   DIVISION. 


PART  I. 

PAGE 

DEVELOPMENT  OF  THE  FEMALE  GENITALS 19 


PART  II. 
ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS 35 

PART  IIL 
PHYSIOLOGY 114 

CHAPTER  I. 
PUBERTY 114 

CHAPTER  H. 
MENSTRUATION  AND  OVULATION 115 

CHAPTER  IIL 
COPULATION 121 

CHAPTER  IV. 
FECUNDATION 121 

CHAPTER  V. 
THE  CLIMACTERIC 103 


PART  IV. 
ETIOLOGY  IN  GENERAL  . 


PART  V. 

EXAMINATION  IN  GENERAL 


Verbal  Examination 13:2 

Age 13-2 

Social  Position  and  Pursuits       132 

Duration  of  Sickness 132 

Condition 132 

Childbirth  and  Miscarriages 132 

5 


6  CONTENTS. 

PAGE 

Menstruation 133 

Discharge 134 

Micturition  and  Defecation 134 

Pain 134 

Nutrition  and  Strength 134 

Family  History 134 

Special  Questions 135 

Physical  Examination 135 

I.  Positions 136 

II.  Examination  of  the  Pelvis 139 

A.  Inspection 139 

B.  Digital  Examination 139 

C.  Artificial  Prolapse  of  the  Uterus 143 

D.  Specula 143 

E.  Sound 152 

F.  Probe 153 

G.  Curette 153 

H.  Dilatation 154 

I.  Examination  of  Virgins 156 

III.  Examination  of  the  Abdomen ]  57 

A.  Inspection 157 

B.  Palpation 157 

C.  Percussion 158 

D.  Auscultation 158 

E.  Mensuration 158 

F.  Development  of  Gas  and  Injection  of  Water 158 

G.  Charts 158 

IV.  Other  Means  of  Investigation  common  for  Pelvic  and  Abdominal  Diseases  159 

A.  Exploratory  Aspiration 159 

B.  Exploratory  Incision 159 

C.  Urinary  Analysis 160 

D.  Catheterization  of  the  Bladder 161 

E.  Microscopical  Examination 161 

F.  Chemical  Examination 161 

G.  Examination  under  Anesthesia 161 

H.  Examination  of  the  Bladder  and  the  Ureters 161 


PART  VI. 

TREATMENT  IN  GENERAL 168 

CHAPTER  I. 

PREVENTIVE  TREATMENT 168 

CHAPTER  II. 

EXTERNAL  TREATMENT 170 

A.- Applications '  .    .   .    .  170 

B.  Injections 171 

Vaginal     171 


CONTENTS. 


Intra-uterine   .........................  j-y 

Eectal    .....   ...    .............  174 

Vesical   .....................   •   •   -    .......   175 

C.  Curetting     .........................  173 

D.  Tampoiiade  ..........................  177 

Pledgets  iu  the  Vagina    .......................   178 

Packing  the  Vagina  .........................   173 

The  Hemostatic  Plug   .....................  179 

Tamponade  of  the  Uterus  ........       ..........  .   130 

Abdominal  Tamponade   .......................   131 

E.  Hemostasis  .....................    .....  131 

Hot  Water    .............................   132 

Styptics     ....................    ..........   132 

Cauterization  ........................  Igo 

Ligature   .................    .............   132 

Forcipressure  ............................   134 

F.  Dilatation    .........................  134 

G.  Drainage  ...............................   134 

H.  Bloodletting   ......................  13^ 

I.  Heat  and  Cold   .........................  137 

J.  Counter-irritation     .......................  .  133 

K.  Tapping  and  Aspiration  ....................  .   183 

L.  Abdominal  Belt     .....................  190 

M.  Massage     .........................  190 

N.  Gymnastics     .......................  191 

0.  Operations  in  general  ....................  192 

1.  Time  for  Operating  .........................   192 

2.  Preparation     ............................   193 

Room     ..............................   193 

Table     ..............................   194 

Assistants    ............................   195 

Spectators    ............................  196 

Patient     .....................    '   "    ......  196 

Vessels  and  Towels   ........................  198 

Disinfection,  Asepsis,  and  Antisepsis  ................   198 

Sponges  .............................   200 

Gauze     ............................   -201 

Silk     ..............................   201 

Catgut    .............................   202 

Silkworm  Gut  ..........................   204 

Horsehair  ...........................   204 

Kangaroo  Tendon  ..........    ..............   204 

Silver  Wire  ...........................   204 

lodoform    ...............    .............   205 

Antiseptic  Fluids    ........................   205 

Bichloride  of  Mercury  ....................   205 

Carbolic  Acid   .........................   205 

Creolin  ............................   205 

Lysol  .............................   206 

Hydronaphthol   ........................   206 


8  CONTEXTS. 

PAGE 

Borosalicylic  Solution  (Thiersch's  Solution) 206 

Thymol .206 

3.  Anesthesia 206 

Ether 206 

Chloroform 208 

Cocaine 209 

Chloric  ether 210 

4.  Common  Instruments  and  their  Use 211 

Vaginal  Retractors 211 

Tenacula 212 

Volsellse 212 

Tenaculum-forceps ,    .  213 

Sponge-holders 213 

Knives 213 

Scissors 213 

Pressure-forceps 214 

Needles 214 

Needle-holders 215 

Ligature-carrier 217 

Ligatures 217 

Sutures 217 

Sponging  and  Irrigation 222 

How  to  Clean  and  Keep  Instruments 223 

Selection  of  Instruments 223 

5.  Combination  of  Operations 223 

6.  After-treatment 223 

CHAPTER  III. 

IKTEBNAL  TREATMENT 224 

Food  and  Drink 224 

Aperients 225 

Tonics 226 

Anodynes 226 

Sedatives 226 

Hypnotics 226 

Resolvents 226 

Hemostatics      227 

Antipyretics 228 

CHAPTER   IV. 

ELECTRIC  TREATMENT 229 

Frankliuism 229 

Faradism 229 

Galvanism 229 

Different  Qualities  of  the  Two  Poles 233 

Apostoli's  Method 233 

Chemical  Galvanocauterization  of  the  Cervix 234 

Galvanopuncture 235 

Thermal  Galvanocauterizatiou 235 

Metallic  Interstitial  Electrolysis 236 


CONTEXTS.  9 

PAGE 

PART   VII. 
ABNORMAL  MENSTRUATION   AND   METRORRHAGIA 238 

CHAPTER   I. 
AMENORRHEA 238 

CHAPTER   II. 
VICARIOUS  MENSTRUATION 241 

CHAPTER   III. 
DYSMENORRHEA 242 

CHAPTER  IV. 
PRECOCIOUS  AND  TARDY  MENSTRUATION 244 

CHAPTER  V. 
MENORRHAGIA 245 

CHAPTER   VI. 
METRORRHAGIA 247 

CHAPTER  VII. 
GENERAL  MENSTRUAL  DISORDERS .  247 


PART  VIII. 

LEUCORRHEA  .  .  250 


SPECIAL   DIVISION. 


PART  I. 

DISEASES  OF  THE  VULVA 255 

CHAPTER  I. 

MALFORMATIONS , 255 

1.  Absence  of  the  Vulva 255 

2.  Hypospadias 255 

3.  Epispadias 25(5 

4.  Abnormalities  of  the  Clitoris 256 

5.  Abnormalities  of  the  Labia  Minora 258 

6.  Abnormalities  of  the  Labia  Majora 25S 

7.  Epithelial  Coalescence 25M 

8.  Hermaphrodism 25S 

CHAPTER  II. 
RUPTURES  (HERNIA , 260 

1.  Anterior  Labial,  or  Inguinolabial,  Hernia 2(iO 

2.  Posterior  Labial,  or  Vaginolabial,  Hernia 261 

CHAPTER   III. 

TUMORS  CONNECTED  WITH  THE  EXTRAPELVIC  PORTION  OF  THE  ROUND  LIG- 
AMENT    262 

1.  Hydrocele 262 


10  CONTENTS. 

PAGE 

2.  Hematocele  of  the  Canal  ot  Nuck 263 

3.  Hematoma  of  the  Bound  Ligament 263 

4.  Fibroma  of  the  Bound  Ligament 264 

CHAPTEB  IV. 
INJURIES 265 

CHAPTEB  V. 
VULVITIS 266 

CHAPTEB  VI. 
INFLAMMATION  OF  THE  URETHEAL  DUCTS 270 

CHAPTEB  VII. 
GANGRENE  OF  THE  VULVA 270 

CHAPTEB  VIII. 

EXANTHEMATOUS   DISEASES 271 

Herpes  Progenitalis 271 

CHAPTEB  IX. 
TRICHIASIS 272 

CHAPTEB  X. 

PRURITUS  VULV.E     272 

Burning  Sensation  in  the  Genitals  and  the  Abdomen 274 

CHAPTEB  XI. 
HYPEHESTHESIA  OF  THE  VULVA 275 

CHAPTEB  XII. 

TUMORS  OF  THE  VULVA 275 

1.  Hyperplasia 275 

2.  Varicose  Veins 276 

3.  Hematoma,  or  Thrombus 276 

4.  Papilloma 277 

5.  Elephantiasis,  or  Pachydermia 279 

6.  Fibroma 280 

7.  Myoma,  Myxoma,  Lipoma 281 

8.  Enchondroma  of  the  Clitoris 281 

9.  Horn  of  the  Clitoris 282 

10.  Urethral  Caruncle,  Angioma,  and  Neuroma  of  the  Vulva 282 

11.  Cysts 283 

12.  Cancer     283 

13.  Lupus ;  Esthiomene ;  Chronic  Inflammation,  Infiltration,  and  Ulceratiou  285 

CHAPTEB  XIII. 
TUBERCULOSIS 288 

CHAPTEB  XIV. 
PROGRESSIVE  ATROPHY  OF  THE  NYMPHJE,  OR  KRAUROSIS 288 

CHAPTEB  XV. 
DISEASES  OF  THE  VULVOVAGINAL  GLANDS  .  ....  289 


CONTENTS.  11 

CHAPTER   XVI. 

VENEBEAL  DISEASES .  391 

1.  Gonorrhea 291 

2.  Chancroid 291 

3.  Syphilis 293 

CHAPTER   XVII. 

PROLAPSE  OF  THE  UEETHRA 296 

CHAPTER  XVIII. 

MASTURBATION 297 

Clitoridectomy 300 


PART  II. 

DISEASES  OF  THE  PERINEUM 301 

CHAPTER  I. 

INJURIES 301 

-I.  Injuries  from  Without 301 

II.  Injuries  from  Within 301 

A.  Recent  Lacerations 301 

Primary  Operation 303 

Rupture  of  the  Outer  Ring 303 

Rupture  of  the  Inner  Ring 305 

Intermediate  Operation 307 

B.  Old  Lacerations 307 

1.  Tait's  Flap-splitting  Operation 307 

a.  For  Incomplete  Laceration 307 

b.  For  Complete  Laceration 310 

2.  Colpoperineorrhaphy 311 

a.  Hegar-Garrigues'  for  Incomplete  Laceration 311 

6.  Hegar's  for  Complete  Laceration 314 

3.  T.  A.  Emmet's  Operation 316 

a.  For  Incomplete  Laceration  (the  new  operation) .  316 

b.  For  Complete  Laceration 320 

Preparation  and  After-treatment 322 

CHAPTER   II. 

GARRULITY  OP  THE  VULVA,  OR  FLATUS  VAGINALIS 323 

CHAPTER  III. 

COCCYGODYNIA £23 

CHAPTER   IV. 

HYGROMA  PERIN^I  ....  .  325 


PART  III. 
DISEASES  OF  THE  VAGINA 32t> 

CHAPTER  I. 

MALFORMATIONS    .  .   . , 32ti 


12  CONTENTS. 

PAGE 

A.  Malformations  of  the  Hymen 326 

1.  Absence  of  the  Hymen 326 

2.  Atresia  Hymenalis 326 

3.  Abnormal  Openings  in  the  Hymen 328 

4.  Double  Hymen     328 

5.  Fleshy  Hymen      328 

B.  Malformations  of  the  Vagina 328 

1.  Atresia  and  Stenosis  of  the  Vagina 328 

2.  Double  Vagina 332 

3.  Blind  Canals  in  the  Vagina 333 

4.  Faulty  Communications  of  the  Vagina 333 

CHAPTER  II. 
VAGINAL  ENTEEOCELE •   •   • 334 

CHAPTER  III. 
PROLAPSE  OF  THE  ANTERIOR  WALL  OF  THE  VAGINA  ;  CYSTOCELE 335 

CHAPTER  IV. 

PROLAPSE  OF  THE  POSTERIOR  WALL  OF  THE  VAGINA;  RECTOCELE 340 

GENERAL  PROLAPSE  AND  INVERSION 340 

CHAPTER  V. 
INJURIES;  THROMBUS,  OR  HEMATOMA 341 

CHAPTER  VI. 
FOREIGN  BODIES    ....".. 342 

CHAPTER  VII. 
VAGINITIS 343 

A.  Catarrhal  Vaginitis 344 

Exfoliative  Vaginitis 348 

Emphysematous  Vaginitis 349 

Mycotic  Vaginitis 349 

B.  Exudative  Vaginitis 350 

C.  Phlegmonous  Vaginitis 351 

CHAPTER  VIII. 
GANGRENE • 352 

CHAPTER  IX. 
ERYSIPELAS 353 

CHAPTER  X. 
CICATRICES 353 

CHAPTER  XI. 
VAGINISMUS 355 

CHAPTER  XII. 

NEOPLASMS 353 

1-  Cysts .  358 


CONTENTS.  13 

PAGE 

2.  Fibroids 359 

3.  Mucous  Polypi    .    . 361 

4.  Sarcoma 361 

5.  Carcinoma 361 

6.  Tuberculosis 362 

CHAPTER   XIII. 
FISTULA 363 

A.  Urinary  Fistulas 363 

1.  Vesicovaginal  Fistula 363 

2.  Urethrovagiual  Fistula 373 

3.  Ureterovaginal  Fistula 373 

4.  Vesico-uterine  Fistula 376 

5.  Vesico-utero vaginal  Fistula     377 

6.  Uretero-uterine  Fistula 377 

7.  Ureterovesicovaginal  Fistula 377 

Genital  Cleisis      378 

Urinals 378 

Operations  for  Incontinence 379 

B.  Fecal  Fistulas      380 

PART  IV. 

DISEASES  OF  THE  UTERUS 387 

CHAPTER  I. 
MALFORMATIONS 387 

A.  Excessive  Development  and  Precocity 387 

B.  Arrest  of  Development  during  the  First  Half  of  Intra-uteriue  Life  .    .    .  387 

1.  Absence  of  the  Uterus 387 

2.  Rudimentary  Uterus 388 

3.  Uterus  Duplex  Separatus,  or  Uterus  Didelphys 388 

4.  Uterus  Unicornis 389 

5.  Uterus  Bicornis .    .  390 

6.  Uterus  Septus,  or  Uterus  Bilocularis .  390 

7.  Atresia  Uteri 391 

C.  Arrest  of  Development  during  the  Second  Half  of  Tntra-uterine  Life    .    .  392 

1.  Fetal  and  Infantile  Uterus 392 

2.  Pubescent,  or  Congenitally  Atrophic,  Uterus 393 

3.  Uterus  Parvicollis  and  Acollis      393 

4.  Congenital  Anteflexion 394 

D.  Irregular  Development 394 

1.  Obliquity 394 

Lateroflexion 394 

Lateroversion 394 

2.  Malposition 394 

Lateroposition 394 

Anteposition 394 

Retroposition 394 

3.  Hernia  Uteri     394 

4.  Elongated  Cervix  and  Stenosis  of  the  Cervical  Canal 394 


14  CONTENTS. 


CHAPTER  II. 
INJURIES 394 

A.  Injuries  of  the  Body 394 

B.  Laceration  of  the  Cervix 396 

CHAPTER  III. 
FOREIGN  BODIES 403 

CHAPTER  IV. 

METRITIS 403 

A.  Acute  Metritis 403 

Diphtheritic  Metritis 406 

Dissecting  Metritis 406 

B.  Chronic  Metritis 407 

1.  Chronic  Endometritis 407 

2.  Chronic  Parenchymatous  Metritis 416 

CHAPTER  V. 
CLOSURE  OF  THE  UTERUS  (ACQUIRED  ATRESIA) 420 

CHAPTER  VI. 
STENOSIS  OP  THE  CERVIX 421 

CHAPTER  VII. 
ULCERS  OP  THE  CERVIX 424 

CHAPTER  VIII. 
HYPERTROPHY  OF  THE  UTERUS 404 

A.  Infravaginal  Hypertrophy  of  the  Cervix 425 

B.  Supravaginal  Hypertrophy  of  the  Cervix 426 

CHAPTER  IX. 
ACQUIRED  ATROPHY  or  THE  UTERUS  (SUPERINVOLUTION) 431 

CHAPTER  X. 
GANGRENE  OF  THE  UTERUS 432 

CHAPTER  XI. 
HYSTERALGIA 432 

CHAPTER  XII. 
DISPLACEMENTS  OF  THE  UTERUS  .          433 

A.  Anteversion 433 

B.  Auteflexion 43g 

C.  Retrovereion 442 

D.  Retroflexion 443 

E.  Lateroversion  and  Lateroflexion 454 

F.  Prolapse 454 

G.  Elevation 460 

H.  Inversion •.   .  459 

I.    Hernia 466 


CONTENTS.  15 

PAGE 

CHAPTER   XIII. 

NEOPLASMS  OF  THE  UTERUS 467 

A.  Cysts :  Adenoma ;  Mucous  Polypi ;  Myxoma 467 

B.  Cavernous  Angioma      468 

C.  Fibroids,  Fibroid  Polypi,  and  Fibrocysts 469 

D.  Sarcoma 503 

E.  Carcinoma 507 

F.  Papilloma 521 

G.  Euchoudroma 522 

H.  Tuberculosis .  522 


PART  V. 

DISEASES  OF  THE  FALLOPIAN  TUBES 524 

CHAPTER  I. 

MALFOBMATIONS 524 

CHAPTER  II. 

SALPINGITIS * 525 

Cystic  Salpingitis 541 

Pyosalpinx 543 

Hydrosalpinx 544 

Hematosalpinx 545 

CHAPTER  III. 

DISPLACEMENTS 546 

CHAPTER  IV. 

NEOPLASMS 546 

A.  Cysts 546 

B.  Fibroma 547 

C.  Lipoma 547 

D.  Papilloma 547 

E.  Cancer  (Carcinoma  and  Sarcoma) 547 

F.  Tuberculosis   .   .  .  547 


PART  VI. 

DISEASES  OF  THE  OVARIES 549 

CHAPTER  I. 
MALFORMATIONS 549 

CHAPTER  II. 

DISPLACEMENTS 550 

Extrapelvic  Displacements 550 

Intrapelvic  Displacements,  or  Prolapse 551 

CHAPTER  III. 
HYPEEEMIA  AND  HEMATOMA  .  ....  554 


16  CONTEXTS. 

PAGE 

CHAPTER  IV. 

OOPHORITIS 557 

A.  Acute  Oophoritis  and  Ovarian  Abscess 557 

B.  Chronic  Oophoritis 559 

Gyroma  and  Endothelioma 563 

CHAPTER  V. 
NEOPLASMS 567 

A.  Ovarian  Cysts 567 

I.  Dropsical  Graafian  Follicles    .   .   . •    .   .  568 

Rokitanski's  Tumor 570 

II.  Proliferating  Cysts • 571 

a.  Glandular 572 

b.  Papillary • 580 

e.  Mixed 581 

III.  Dermoid  Cysts 581 

IV.  Tubo-ovarian  Cysts,  or  Hydrocele  of  the  Ovary 583 

Origin  of  Ovarian  Cysts 587 

Etiology 588 

Symptoms 588 

Accidents 593 

Hemorrhage 593 

Inflammation  and  Suppuration 593 

Torsion  of  the  Pedicle 593 

Rupture  of  the  Cyst .  593 

Ascites 594 

Peritonitis 594 

Intestinal  Obstruction 594 

Explorative  Puncture 595 

Diagnostic  Value  of  the  Fluid 595 

Explorative  Incision 596 

Differential  Diagnosis 596 

A.  Pelvic  Tumor 596 

B.  Abdominal  Tumor 597 

Complications 602 

Prognosis 603 

Treatment 603 

Tapping     604 

Ovariotomy 606 

Vaginal  Ovariotomy 607 

Abdominal  Ovariotomy 607 

Difficulties  met  with  during  Operation 616 

Incomplete  Operations 623 

Complications  of  Ovarian  Cysts 629 

Complications  during  After-treatment 631 

Prognosis  of  Ovariotomy 635 

B.  Solid  Ovarian  Tumors      636 

I.  Fibroma •  .    .    .  636 

II.  Papilloma     637 

III.  Sarcoma 638 

IV.  Endothelioma  (Ackermann) 639 


CONTENTS.  17 

PAGE 

V.  Carcinoma 639 

VI.  Tuberculosis _  641 


CHAPTEE   VI. 


Ob'PHOBALGIA 


642 


PART  VII. 

DISEASES  OF  THE   PELVIS .643 

(The  Peritoneum,  the  Connective  Tissue,  the  Vessels  of  the  Pelvis,  and  the  Liga- 
ments of  the  Uterus.) 

CHAPTER  I. 
MALFORMATIONS 643 

CHAPTER  II. 
ANEURYSM  OF  THE  UTEEINE  ARTERY     643 

CHAPTER  III. 

DISEASES  OF  THE  BROAD  LIGAMENT 644 

A.  Varicocele 644 

B.  Cysts 645 

C.  Solid  Tumors 648 

CHAPTER  IV. 
DISEASES  OF  THE  ROUND  LIGAMENT     648 

CHAPTER  V. 
DISEASES  OF  THE  SACRO-TJTERINE  LIGAMENT 648 

CHAPTER  VI. 

PELVIC  HEMORRHAGE 649 

A.  Intraperitoneal  Hemorrhage 649 

B.  Hematocele     650 

C.  Hematoma 655 

CHAPTER  VII. 
PERIMETRIC  INFLAMMATION 657 

A.  Pelvic  Peritonitis 657 

B.  Pelvic  Cellulitis 669 

C.  Pelvic  Phlebitis •  .    .    .    H75 

D.  Pelvic  Lymphangitis  and  Lymphadenitis 

CHAPTER  VIII. 
SARCOMA  AND  CARCINOMA  OF  THE  PELVIC  PERITONEUM  AND  CONNECTIVE 

TISSUE 678 

CHAPTER  IX. 
HYDATIDS  OF  THE  PELVIS  <579 


APPENDIX. 

I.  STERILITY  . 68:2 

II.  LACK  OF  ORGASM 687 

III.  INTESTINAL  SURGERY 688 


DISEASES  OF  WOMEN 


OR 


GY. 


GENERAL  DIVISION. 


DISEASES  OP  WOMEN. 


GENERAL  DIVISION". 


PART  I. 

DEVELOPMENT  OF  THE  FEMALE  GENITALS. 

THE  history  of  the  development  of  the  female  genitals  being  an 
indispensable  key  to  the  understanding  of  their  malformations,  which 
are  of  frequent  occurrence  and  often  of  great  importance  in  regard 
to  life  and  happiness,  we  give  here  a  resume  of  the  same.* 

THE  WOLFFIAN  DUCTS. 

The  first  organs  belonging  to  the  genital  sphere  which  appear  in 
the  male  as  well  as  the  female  embryo  are  the  Wolffian  ducts. 
There  is  one  on  either  side  of  the  body,  situated  between  the  proto- 


Transverse  Section  through  the  Median  Part  of  the  Body  of  the  Embryo  of  a  Rabbit  of  nine 
days  and  two  hours  (enlarged  158  times):  dd,  hypoblast :  dr,  intestinal  groove:  ch,  noto- 
chord  ;  ao,  descending  aortse ;  un,  protovertebra  f  mr,  medullary  tube  ;  itny,  Wolffian  durt : 
O/p,  visceral  division  of  the  mesoblast ;  g,  vessels  in  the  deeper" parts  of  the  visceral  meso- 
blast ;  hp,  parietal  mesoblast ;  h,  epiblast ;  pp,  pleuro-peritoneal  cavity  (Kolliker). 

vertebral  column  and  the  lateral  plates  (Fig.  1).    Originally  it  is  a 

*  This  is  an  abstract  of  the  author's  more  elaborate  article  on  the  subject  in  A 
System  of  Gynecology  by  American  Authors,  edited  by  M.  D.  Mann,  Philadelphia, 
1887. 

19 


20 


DISEASES  OF  WOMEN. 


solid  string,  but  it  is  later  tunnelled,  so  as  to  form  a  tube.  The 
upper  end  lies  on  a  level  with  the  fourth  or  fifth  vertebra,  and  con- 
nects soon  with  the  Wolffian  body,  forming  its  outlet.  The  lower 
end  opens  into  that  part  of  the  allantois  which  is  situated  in  the 
body  of  the  embryo  and  communicates  with  the  cloaca.  After  the 
separation  between  the  urogenital  canal  and  the  intestine  the  "W  olf- 
fian  duct  ends  in  the  urogenital  sinus  (Fig.  2). 

FIG.  2. 


Sagittal  Section  through  the  Posterior  Part  of  the  Body  of  the  Embryo  of  a  Rabbit  of  eleven 
days  and  ten  hours  (enlarged  45  times) :  wg,  Wolffian  duct;  n,  ureter;  «',  beginning  formation 
of  the  kidney ;  ug,  urogenital  sinus ;  cl,  cloaca ;  hg,  region  in  which,  in  the  mesial  plane, 
the  hind-gut,  opens  into  the  cloaca ;  ed,  post-anal  gut ;  a,  anus,  or  fissure  of  the  cloaca ;  s, 
tail ;  r,  perinea!  fold  (Kolliker). 

In  the  male  the  Wolffian  duct  becomes,  in  the  course  of  time,  the 
tail  of  the  epididymis  and  the  vas  deferens.  In  the  female  it  disap- 
pears more  or  less  completely.  Still,  in  the  cow  and  the  sow  it  per- 
sists as  Gartner's  canal.  In  woman  remnants  of  it  are  found  in  the 
broad  ligaments. 

THE  WOLFFIAN  BODIES. 

Shortly  after  the  Wolffian  ducts  appear  the  Wolffian  bodies. 
These  are  two  long  prismatic  bodies,  one  on  either  side  of  the 
median  line  (Fig.  3).  The  upper  end  is  fastened  to  the  dia- 
phragm, the  lower  to  the  inguinal  region  by  a  ligament  which  in 
course  of  time  becomes  the  round  ligament  of  the  uterus,  or  the 
gubernaculum  testis  in  the  male  (Fig.  4).  They  fill  the  hollow  of 
the  posterior  wall  of  the  abdominal  cavity,  leaving  a  narrow  fissure 
on  either  side.  In  the  inner  one  of  these  is  later  developed  the  gen- 
ital gland ;  in  the  outer  lies  the  Wolffian  duct,  and  later  also  the 
Miillerian  duct. 


DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


21 


These  bodies  originate  from  the  endothelium  of  the  peritoneum, 
and  form  at  first  a  long  row  of  pear-shaped  solid  bodies.     Later, 


FIG.  3. 


Human  Embryo  of  thirty-five  days  (front  view) :  3,  left  external  nasal  process  ;  4,  superior 
maxillary  process ;  z,  tongue ;  b,  aortic  bulb ;  6',  first  permanent  aortic  arch  ;  6",  second 
aortic  arch  ;  b'",  third  aortic  arch,  or  ductus  Botalli  ;  y,  the  two  filaments  to  the  right  and 
the  left  of  this  letter  are  the  pulmonary  arteries,  which  just  begin  to  be  developed  ;  c,  the 
trunk  of  the  superior  vena  cava  and  right  azygos  vein  ;  c',  the  common  venous  sinus  of 
the  heart ;  c",  the  common  trunk  of  the  left  vena  cava  and  left  azygos  vein  ;  o,  left  auricle 
of  the  heart;  v,  right  ventricle ;  v',  left  ventricle ;  ae,  lungs;  e,  stomach;  ?',  left  omphalo- 
mesenteric  vein  ;  s,  continuation  of  the  same  behind  the  pylorus,  which  afterward 
becomes  the  vena  porta;  x,  vitello-intestinal  duct;  o,  right  pmphalo-mesenteric  artery; 
m,  Wolman  body;  i,  gut ;  n,  umbilical  artery  ;  u,  umbilical  vein  ;  8,  tail ;  9,  anterior  limb  ; 
9',  posterior  limb.  The  liver  has  been  removed.  The  white  band  at  the  inner  side  of  the 
Wolman  body  is  the  genital  gland,  and  the  two  white  bands  at  its  outer  side  are  the  Miil- 
lerian  and  the  Wolman  ducts  (Coste). 

these  are  separated  from  the  peritoneum  and  become  hollow,  form- 
ing a  row  of  vesicles  called  the  segmented  vesicles,  each  of  which  soon 
connects  with  the  Wolffian  duct  by  the  absorption  of  the  tissue  inter- 
vening between  their  cavities  and  the  bore  of  the  duct.  The  former 


22 


DJSEASES  OF  WOMEN. 


vesicles  appear  now  as  branches  of  the  Wolffian  duct  (Fig.  5),  which 
grow  rapidly  and  connect  at  the  other  end  with  arterial  tufts  in  the 
same  way  as  the  uriniferous  ducts  and  the  Malpighian  tufts  in  the 
kidneys. 

In  the  male  the  Wolffian  body  later  is  transformed  into  the  epidi- 
didymis  and  the  organ  of  Giraldez  (Fig.  6) ;  in  the  female  into  Rosen- 


FTG.  4. 


The  Genital  and  Urinary  Organs  of  the  Embryo  of  Cattle  : 

1,  from  a  female  embryo  1%  inches  long  (double  size) :  w,  Wolffian  body  ;  wg,  Wolffian  and 

Mullerian  dncts ;  i,  inguinal  ligament  of  Wolffian  body  ;  o,  ovary  with  an  upper  and  lower 
peritoneal  fold  :  n,  kidney  ;nn,  suprarenal  body;  g,  genital  cord,  composed  of  the  united 
Wolffian  and  Mullerian  ducts. 

2,  from  a  male  embryo  2]4  inches  long  (nearly  three  times  natural  size) :  one  of  the  testicles 

has  been  removed.  Letters  as  in  Fig.  1,  and,  besides,  m,  Mullerian  duct ;  TO',  upper  end 
of  the  same  :  h,  testicle  ;  h',  lower  ligament  of  testicle ;  h",  upper  ligament  of  testicle ;  d, 
diaphragmatic  ligament  of  Wolffian  body ;  a,  umbilical  artery ;  v,  bladder. 
8,  from  a  female  embryo  (enlarged  nearly  three  times).  Letters  as  in  Figs.  1  and  2,  and,  be- 
sides, t,  opening  of  the  upper  end  of  Muller's  duct ;  o',  lower  ovarian  ligament ;  u,  thick- 
ened part  of  Mullerian  duct,  which  later  becomes  the  uterine  horn  (Kolliker). 

mulleins  organ,  or  the  parovarium,  and  stray  tubes  found  between 
the  parovarium  and  the  uterus  (Fig.  7). 

THE  OVARIES. 

In  the  beginning  the  sexual  glands  are  identical  in  both  sexes. 
At  the  end  of  the  second  month  the  ovary  and  the  testicle  begin  to 
differ  from  one  another,  the  testicle  becoming  broader  and  shorter, 
while  the  ovary  stays  long  and  narrow.  The  ovary  has  a  much  more 
developed  columnar  epithelium  than  the  testicle. 

The  sexual  glands  are  situated  on  the  inner  side  of  the  Wolffian 
body  (Fig.  4),  to  which  they  are  fastened  by  a  fold  of  the  peritoneum 


DEVELOPMENT  OF  THE  FEMALE  GENITALS.  23 

called  the  mesorchium  in  the  male  and  the  mesoarium  in  the  female. 
At  the  upper  end  is  a  ligament  which  unites  with  the  diaphragmatic 
ligament  of  the  Wolffian  body ;  at  the  lower  end  is  another  ligament, 
which  is  fastened  to  the  Wolffian  duct,  opposite  the  starting-point  of 
the  inguinal  ligament  of  the  Wolffian  body,  and  which  later  becomes 
the  permanent  ligament  of  the  ovary. 

The  shape  of  the  ovary  undergoes  great  changes.  At  first  it  is  a 
long  flat  body.  Later  it  grows,  especially  at  the  edges,  so  that  a 
transverse  section  has  the  shape  of  a  bean  or  a  mushroom  (Fig.  8), 
and  finally  the  transverse  section  becomes  pear-shaped. 

The  ovary  is  subject  to  a  descent  just  as  the  testicle.  At  the  birth 
of  the  child  the  ovaries  are  yet  situated  above  the  ileo-pectineal  line, 
and  descend  into  the  true  pelvis  during  the  first  two  or  three  months 


Posterior  End  of  the  Embryo  of  a  Dog,  with  budding  alantoid.  The  mesoblast  and  the  hypo- 
blast,  or  the  beginning  of  the  intestine  and  the  neighboring  parts  of  the  blastodefmic 
vesicle,  are  thrown  back  in  order  to  show  the  Wolffian  bodies  (enlarged  10  times),  a, 
Wolffian  bodies,  with  the  duct  and  the  single  blind  canals ;  6,  proto vertebrae  ;  c,  spinal 
marrow  ;  d,  entrance  to  the  pelvic  intestinal  cavity  (Bischoff). 

of  the  child's  life.  This  descent  is  partly  apparent  and  partly  real : 
it  is  chiefly  due  to  the  greater  growth  of  the  parts  above  the  ovaries  ; 
but,  besides  that,  a  shrinking  of  the  round  ligament  of  the  uterus 
takes  place,  by  which  the  ovaries  indirectly  are  pulled  down.  At  the 
same  time  there  is  a  change  in  position  by  which  the  upper  end  sinks 
considerably  downward  and  outward,  and  the  whole  organ  turns 
around  its  long  axis  until  the  inner  edge  becomes  the  lower,  where 
the  hilum  is ;  the  outer  becomes  the  upper,  free  edge ;  the  anterior 
surface  becomes  the  inner,  the  posterior  becomes  the  outer.  The 
relations  to  the  Fallopian  tube  are  changed  in  such  a  way  that  the 


24 


DISEASES  OF  WOMEN. 


ovary,  instead  of  lying  inside  of  the  Miillerian  duct,  as  it  does  at  first, 
finally  lies  behind  and  below  the  tube. 

FIG.  7. 

Oabd 


FIG.  6. 


E—  -& 


Mp 
U  U    s 

FIG.  6.— Internal  Genitalia  of  a  Human  Fetus,  9  cm.  long  (enlarged  8  times):  H,  testicle  ;  E, 
epididymis  (epididymal  part  of  Wolffian  body) ;  U,  organ  of  Giraldez  (uropoetic  part  of 
Wolffian  body) ;  6,  bundle  of  connective  tissue  containing  vessels ;  Y,  vas  deferens 
(Wolffian  duct)  (Waldeyer). 

FIG.  7. — Internal  Genitalia  of  a  Human  Female  Fetus,  9  cm.  long  (enlarged  10  times) ;  0,  ovary ; 
T,  tube ;  0  abd.,  abdominal  ostium  of  tube  ;  E,  parovarium  ;  U,  uropoetic  part  of  the  Wolff 
ian  body  remaining  as  tubes  between  parovarium  and  uterus ;  Y,  Wolffian  duct  disap- 
pearing lower  down;  Mp.,  Malpigbian  bodies  (Waldeyer). 

The  ovarian  vessels   enter   originally  at  the   upper  end  of  the 


Transverse  Section  of  Ovary  of  Human  Embrvo  of  three  months  (enlarged  43  times) :  a, 
mesoarium :  a',  stroma  of  the  hilum  (medullary  substance) ;  b,  glandular  tissue  (cortical 
substance)  (Kolliker). 


DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


25 


mesoarium  from  the  posterior  wall  of  the  abdomen,  and  are  enclosed 
in  a  fold  of  the  peritoneum,  which  in  the  course  of  time  becomes  the 
infundibulo-pelvic  ligament,  extending  from  the  fimbrise  of  the  tube  to 


FIG.  9. 


Transverse  Section  through  the  Ovarian  Region  of  a  Human  Embryo  of  five  months ;  lower 
surface  seen  from  above  (enlarged  3  times) :  oi,  os  ilium ;  s,  sacrum  ;  mo,  mesoarium  and 
hilum  of  ovary,  bounded  by  two  lips ;  o,  cut  surface  of  the  ovary ;  i>,  free  ventral  surface, 
or  lateral  part  of  the  ventral  surface,  of  the  ovary ;  m,  rectal  surface  of  ovary,  or  medial 
part  of  its  ventral  surface ;  t,  tube ;  mi,  mesentery  of  tube  (later  ala  vespertilionis) ;  r, 
rectum ;  M,  uterus ;  wr.  ureter ;  au,  umbilfcal  artery ;  ie,  external  iliac  vessels ;  nc,  ante- 
rior crural  nerve  (Kolliker). 

the  wall  of  the  pelvis.    To  the  outer  side  of  the  mesoarium  is  attached 
the  mesosalpinx  (Fig.  9),  or  mesentery  of  the  tube,  which  later  is  called 

FIG.  10. 


Ovary  of  a  Human  Fetus  of  ten  or  eleven  weeks :  a,  superficial  stratum  of  cells :  b,  layer  of 
connective  tissue :  c,  trabeculse  of  connective  tissue,  the  cells  having  been  removed ;  d, 
mesoarium ;  e,  part  near  surface  seen  with  higher  power ;  n,  natural  size  of  the  specimen 
(H.  Meyer). 


26 


DISEASES  OF  WOMEN. 


cda  vespertilionis  (the  bat's  wing),  and  contains  the  remnants  of  the 
Wolffian  body,  especially  the  parovariura,  but  at  this  period  has  no 
connection  with  the  uterus. 

The  Formation  of  Ova  and  Graafian  Follicles. — At  the  earliest 
stage  the  ovary  is  represented  by  a  mass  of  cells  developed  from  the 
peritoneal  cover  of  the  Wolffian  body,  and  soon  a  protuberance  of 
connective  tissue  enters  from  behind  into  this  cell-mass.  These  two 
elements  build  up  the  whole  ovary,  the  cells  forming  the  parenchyma, 
or  glandular  element,  and  the  connective  tissue  the  stroma.  Pro- 

FIG.  11. 


Part  of  Ovary  near  Surface,  from  Human  Fetus  of  sixteen  weeks,  showing  formation  and 
separation  of  ova  (H.  Meyer). 

FIG.  12. 


Part  of  Ovary  near  Surface,  from  Human  Fetus  of  twenty-eight  weeks.    In  some  places 
appears  the  permanent  epithelium,  composed  of  a  single  layer  (H.  Meyer). 

FIG.  13. 


Part  of  Ovary  near  Surface,  from  a  Human  Fetus  of  thirty-six  weeks.    The  single  layer  of 
epithelium  is  interrupted  by  a  belated  primordial  ovum  with  its  follicular  epithelial  cells 

longations  from  the  connective  tissue  grow  in  between  the  cells  and 
separate  them,  forming  groups,  and  grow  together  over  them;  but 
from  this  cover  new  prolongations  start,  and  new  cells  are  constantly 
formed  on  the  surface  (Fig.  10).  '  In  this  way  irregular  tubes  filled 


DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


27 


with  cells  are  formed  which  connect  with  one  another,  much  like  the 
canals  found  in  a  sponge  (Figs.  11,  12,  13j;  but  finally  the  whole 
surface  is  only  covered  by  a  single  layer  of  cells,  the  columnar  epi- 
thelium, under  which  is  found  a  layer  of  connective  tissue,  the  albu- 
ginea,  and  under  that  we  find  clusters  of  cells  surrounded  by  connect- 
ive tissue  (Fig.  14),  or  sometimes  a  long  row  of  large  cells,  each 

FIG.  14. 


Part  of  Section  from  Surface  to  Hiluiu  of  Ovary  of  Girl  three  days  old  :  s,  single  layer  of  epi- 
thelium yet  in  connection  with  cluster  of  primordial  ova.  All  ova  have  disappeared  from 
the  surface.  A  broad  layer  of  stroma  separates  in  most  places  the  epithelium  from  the 
follicular  zone.  The  farther  we  go  from  the  surface  toward  the  hilurn.  the  fewer  ova  are 
there  in  one  nest,  until,  finally,  there  is  only  one  in  its  primary  follicle  ;  n,  natural  size 
of  the  whole  ovary  (H.  Meyer). 

surrounded  by  smaller  cells,  until  finally  all  these  clusters  and  col- 
umns are  broken  up  into  small  compartments,  each  containing  one 


28 


DISEASES  OF  WOMEN. 


large  cell  and  one  or  more  smaller  ones  (Fig.  15).     The  large  cells 
have  each  a  large  nucleus  and  nucleolus,  and  are  the  future  ova,  and 


FIG.  15. 


FIG.  16. 


Perpendicular  Section  through  the  Ovary  of  a  Bitch  of  six  months  (Hartnack,  ?) :  a,  the  epi- 
thelium ;  6,  epithelial  pouch  opening  on  the  surface  ;  c,  larger  group  of  follicles ;  d,  ovarian 
tube  filled  with  ova;  e,  oblique  and  transverse  sections  of  ovarian  tubes  (Waldeyer). 

are  called  primwdial  ova  ;  and  the  small  cells  multiply  and  form  the 
epithelium  of  the  primary  follicles,  which  are  the  beginning  of  the 

Graafian  follicles  (Fig.  16). 

The  small  cells  increase  in  number 
and  form  several  layers.  A  fissure  is 
formed  between  them,  and  a  fluid  ac- 
cumulates in  this  space,  the  beginning 
of  the  future  liquor  folliculi.  The  outer 
layers  form  the  epithelium  of  the  Graaf- 
ian follicle,  the  so-called  membrana 
granulosa ;  the  inner  continue  to  sur- 
round the  ovum,  forming  the  discus 
proligerus  (Fig.  1 7).  The  fibrous  mem- 
brane of  the  follicles  is  formed  by  a  dif- 
ferentiation of  the  surrounding  stroma. 
It  will  be  seen  from  the  above  de- 
scription that  the  ova,  the  surface  epi- 
thelium of  the  ovary,  and  the  epithe- 
lium of  the  Graafian  follicles  have  all 
one  common  origin,  the  cellular  mass 

formed  on  the  inner  edge  of  the  Wolffian  body.  As  mother  to  so 
many  epithelial  formations,  this  is  called  the  germ-epithelium.  The 
formation  of  ova  on  the  surface  of  the  ovary  ceases  from  the  time 
the  single  layer  of  epithelium  is  formed,  about  the  end  of  the  seventh 
month,  but  it  seems  that  the  ova  themselves  multiply  by  division 


Three  Graanan  Follicles  from  the 
Ovary  of  a  New-born  Girl  (en- 
larged 350  times) :  1,  natural  condi- 
tion :  2,  treated  with  acetic  acid ; 
a,  structureless  membrane ;  6,  epi- 
thelium (membrana  granulosa) ;  c, 
yolk :  d.  germinal  vesicle,  with  ger- 
minal spot;  e,  nuclei  of  the  epi- 
thelial cells ;/,  vitelline  membrane 
(Kolliker). 


DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


29 


(Fig.  18).     Their  number  is  enormous:  it  has  been  computed  that 
the  two  ovaries  together  contain  72,000  ova. 


THE  MULLERIAN  DUCTS. 

The  Miillerian  ducts  appear  shortly  after  the  Wolffian  body  as  a 
funnel-shaped  invagiuatiou  from  the  endothelium  of  the  peritoneum 


FIG.  17. 


Graafian  Follicle  from  a  Girl  seven  months  old  (enlarged  220  times  ;  natural  size,  0.351  mm. 
longest  diameter) :  a,  epithelium  (membrana  granulosa)  detached  from  fibrous  membrane ; 
b,  discus  proligerus,  situated  far  away  from  the  surface.  It  contains  the  ovum,  on  which 
the  zona  pellucida  and  the  germinal  vesicle  are  visible.  The  surrounding  fibrous  mem- 
brane is  not  yet  separated  into  two  layers,  and  there  is  no  distinct  line  of  demarkation 
between  it  and  the  surrounding  stroma'(Kolliker). 

at  the  inner  side  of  the  upper  end  of  the  Wolffian  body  (Fig.  1 9). 
Thence  it  extends  behind  this  body  and  comes  to  lie  outside  of  the 
Wolffian  duct,  but  turns  in  a  spiral  line  round  the  latter,  so  as  to 

FIG.  18. 


Primordial  Ova  undergoing  division,  from  a  Human  Embryo  of  six  months  (enlarged  400 
times) :  1,  two  primordial  ova  surrounded  by  a  common  layer  of  epithelium,  one  of  which 
has  a  prolongation  by  means  of  which  it  probably  was  attached  to  another  ovum,  as  in  2, 
where  two  primordial  9va  are  linked  together  by  a  band  of  protoplasm,  the  whole  sur- 
rounded by  one  epithelial  layer ;  3  primordial  ovum  with  two  nuclei  (germinal  vesicles) 
(Kolliker). 


30 


DISEASES  OF   WOMEN. 


pass  in  front  of  it,  and  finally  lie  behind  it.  The  lower  part  is  at 
first  formed  by  a  solid  column  of  cells  which  later  is  tunnelled  so  as 
to  form  a  tube. 

The  Miillerian  duct  has  a  mesentery,  by  which  it  is  fastened  to  the 
Wolffian  body.  After  the  disappearance  of  that  body  it  springs  from 
the  posterior  abdominal  wall;  still  later  from  the  mesoarium  (Fig.  9), 
until,  finally,  in  the  fully-developed  body  we  find  it  as  part  of  the 
broad  ligament  of  the  uterus. 

In  the  male  the  Miillerian  ducts  soon  disappear,  leaving  as  rem- 
nants the  hydatid  of  Morgagni  on  the  epididymis  and  the  vesicula 

FIG.  19. 


Transverse  Section  through  the  upper  end  of  the  Wolffian  Body  of  the  Etnbryo  of  a  Rahbit  of 
fourteen  days  (enlarged  114  times):  wg,  Wolffian  duct;  m,  connection  between  a  tubule 
of  the  Wolffian  body  with  a  Malpighian  body  :  t,  entrance  to  the  Miillerian  duct  (later  the 
abdominal  ostium  of  the  Fallopian  tube) ;  gg',  mesentery  of  the  Wolffian  body,  containing 
a  glandular  tubule;  IV,  surface  of  the  liver;  hb,  posterior  abdominal  wall;  mg,  lateral  part 
of  the  Miillerian  duct  (Kolliker). 

prostatica  (sinus  copularis,  or  male  uterus).     In  the  female  they  form 
the  Fallopian  tubes,  the  uterus,  and  the  vagina. 

The  Fallopian  Tubes. — The  Fallopian  tubes  are  formed  of  that 
part  of  the  Miillerian  ducts  which  lies  above  the  round  ligament  of 
the  uterus  (the  inguinal  ligament  of  the- Wolffian  body,  Fig.  4). 
The  cells  of  the  wall  form  the  fibrous,  muscular,  and  mucous  coat  of 
the  fully-developed  tube,  and  fringes  grow  out  around  the  abdominal 
opening,  forming  the  fimbrice.  The  duct  follows  the  ovary  in  its 
descent,  and  comes  to  lie  above  and  in  front  of  that  organ,  running 
from  the  upper  corner  of  the  uterus  to  the  wall  of  the  pelvis. 


DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


31 


The   Uterus  and  the   Vagina. — The  part  of  the  Mullerian  ducts 
below  the  round  ligament  forms,  together  with  the  lower  ends  of  the 


FIG.  20. 
3 


/ooi'V* 
i°  !L 


A <U 


FIG.  21. 


Transverse  Section  of  the  Genital  Cord  of  the  Embryo  of  a  Cow,  iy2  inches  long  (enlarged  14 
times) :  1,  from  the  upper  end  of  the  cord  (the  ducts  have  been  "cut  somewhat  obliquely) : 
2,  somewhat  lower  down ;  3  and  4,  from  the  middle  of  the  cord,  showing  incomplete  and 
complete  fusion  of  Miiller's  ducts ;  5,  from  the  lower  end,  showing  the  two  Miillerian 
ducts  separated ;  a,  anterior  side  of  genital  cord  ;  p,  posterior  side  ;  m,  Miiller's  ducts ;  u-g, 
Wolffian  duct  (Kolliker). 

Wolffian  ducts,  a  quadrangular  cord  with  rounded  edges,  the  genital 
cord  (Fig.  20).  The  tissue  that  separates  the  two  Miilleriau  ducts  is 
gradually  absorbed  until  there  is  one  canal  instead 
of  two  at  the  end  of  the  second  month.  The 
genital  cord  is  developed  so  as  to  form  the  uterus 
above  and  the  vagina  below.  While  the  fusion  of 
the  Mullerian  ducts  is  incomplete,  they  are  yet 
separated  above,  forming  the  two  horns  of  the 
uterus  (Fig.  21).  About  the  middle  of  pregnancy 
the  uterus  forms  one  sac  without  horns  (Fig.  22). 
The  Mullerian  ducts  open  into  the  lower  part 
of  the  urachus,  that  part  of  the  allantois  which  is 
included  in  the  body,  and  later  forms  the  bladder 
(Fig.  23).  This  lower  part,  situate  below  the 
openings  of  the  Mullerian  and  Wolffian  ducts,  is 
called  the  urogenital  sinus  (Fig.  2).  Originally 
this  sinus  opens  into  the  cloaca  (Fig.  24).  Later 
a  septum  is  formed,  dividing  the  cloaca  and  thereby 
separating  the  sinus  urogenitalis  from  the  rectum, 
and  the  urogenital  opening  from  the  anus,  and 
forming  the  perineum  (Fig.  25).  The  urogenital 
sinus  grows  much  less  than  the  other  parts.  The 
urethra  is  differentiated  as  a  special  organ  from  the 
bladder,  with  which  it  heretofore  formed  one  sac  called  the  urachus, 
and  the  vagina  is  undergoing  a  great  development.  Thus  the  change 


Ovaries.  Tubes,  and 
Uterus  of  Human 
Embryo  from  the 
tenth  "week,  26  mm 
long:  1, natural  size 
2,  enlarged  4  times. 

a,  round  ligament 

b,  rectum(H.  Meyer; 


32 


DISEASES  OF  WOMEN. 


is  brought  about  that  the  urogenital  sinus,  which  seemed  to  be  a  con- 
tinuation of  the  bladder,  now  appears  as  the  continuation  of  the  vagina, 
and  forms  the  vestibule  (Fig.  26). 


FIG.  22. 


Abdominal  and  Pelvic  Viscera  of  Female  Fetus  of  five  months  (length  from  vertex  to  sole, 
19 cm.) :  t. tube ;  r,  round  ligament ;  v,  bladder ;  u,  umbilical  artery ;  ur,  urachus ;  c,  caecum ; 
pv,  vermiform  appendix  (Kolliker). 

In  the  fifth  and  sixth  months  the  vagina  is  separated  from  the 
uterus  by  the  formation  of  a  ring  (Fig.  26,  3),  which  finally  becomes 
the  vaginal  portion. 


FIG.  23. 


FIG.  24. 


FIG.  25. 


FIG.  23.— all,  allantois,  which  becomes  the  bladder:  r,  rectum ;  m,  Muller's  duct,  which  later  is 
transformed  into  the  vagina;  a,  indentation  of  the  skin,  which  forms  the  anus  (Schroeder). 

FIG.  24.— cl,  cloaca  ;  all,  allantois;  m,  Muller's  duct ;  r,  rectum  (Schroeder). 

FIG.  25.— su,  urogenital  sinus ;  r.  rectum,  separated  from  the  former  by  the  perineum ;  v, 
vagina  (lower  part  of  Muller's  duct) ;  6,  bladder ;  «,  urethra  (Schroeder). 

About  the  same  time  the  cervix  is  being  distinguished  from  the 


DEVELOPMENT  OF  THE  FEMALE  GENITALS.  33 

body  of  the  uterus  by  the  formation  of  transverse  folds  on  its  mucous 
membrane. 

In  the  new-born  child  the  cervix  is  nearly  twice  as  long  as  the 
body  of  the  uterus,  and  its  walls  are  much  thicker.  The  anterior 
and  posterior  surfaces  of  the  body  have  longitudinal  folds,  and  in 
either  edge  is  found  another  longitudinal  ridge  from  which  start  to 
both  sides  fine  transverse  folds,  ending  at  the  longitudinal  folds  of 
the  surfaces..  They  are  a  continuation  of  the  transverse  folds  of  the 
cervix.  Later  in  life  all  these  folds  disappear  from  the  cavity  of  the 
body  of  the  uterus,  while  those  in  the  cervix  remain. 

During  the  first  ten  or  twelve  years  of  the  child's  life  the  uterus 
changes  very  little,  even  in  size,  but  at  the  approach  of  menstruation 
the  organ  undergoes  a  great  development ;  and  this  increase  in  size 

FIG.  26. 


V  (I 
*J  • 

Urogenital  Sinus  and  its  Appendages,  from  Human  Embryos  (life-size) :  1,  from  a  three- 
months'  fetus  ;  2,  from  a  four-months' ;  3,  from  a  six-months'  ;  6,  bladder  ;  h,  urethra ;  ug, 
urogenital  sinus  ;  g,  genital  canal  (common  rudiment  of  vagina  and  uterus) ;  s,  vagina  ; 
M,  uterus  (Kolliker). 

continues  until  the  rest  of  the  body  has  attained  the  limit  of  its 
growth. 

After  the  differentiation  between  the  uterus  and  the  vagina,  about 
the  middle  of  pregnancy,  the  vagina  becomes  much  wider,  and  its 
columns  and  rugae  make  their  appearance. 

The  Hymen. — The  hymen  is  formed  in  the  fifth  month  by  a  devel- 
opment of  the  posterior  wall  of  the  vagina. 

THE'VUI,VA. 

We  have  seen  that  originally  the  urogenital  and  the  digestive  tract 
open  into  one  common  cavity  called  the  cloaca.  Toward  the  end  of 
the  first  month  the  cloaca  opens  on  the  surface  of  the  body  by  a  slit 
called  the  cloacal  opening.  In  front  of  this  opening  there  appears  in 
the  sixth  week  a  protuberance  called  the  genital  tubercle,  which  soon 
thereafter  is  surrounded  by  two  lateral  folds  called  the  genital  folds. 
The  genital  tubercle  grows,  and  toward  the  end  of  the  second  month 


34 


DISEASES  OF   WOMEN. 


there  is  formed  a  groove  on  its  lower  surface  which  extends  to  the 
cloacal  opening,  and  is  called  the  genital  furrow  (Fig.  27). 

So  far,  the  organs  are  identical  in  both  sexes,  and  they  cannot  be 

distinguished  before  the  tenth  week. 
The  genital  tubercle  becomes  the 
clitoris,  the  genital  folds  form  the 
labia  majora,  the  edges  of  the  geni- 
tal furrow  are  developed  into  the 
labia  minora,  a  fold  of  which  later 
surrounds  the  clitoris,  forming  its 
prepuce. 

In  the  tenth  week  the  separation 
between  the  rectum  and  the  uro- 
genital  sinus  is  consummated.  The 
genital  folds  grow  together  at  their 
posterior  end,  forming  a  perineum, 
which  unites  with  the  partition  be- 
tween the  urogenital  sinus  and  the 
rectum.  While  at  first  the  two 
canals  are  in  close  contact,  in  the 
fourth  month  there  is  a  well-formed 
perineal  body  between  them. 

In  the  male  the  genital  tubercle 
forms  the  penis  ;  the  edges  of  the 
genital  furrow  grow  together,  form- 
ing the  urethra;  and  the  genital 
folds  form  the  scrotum  and  peri- 
neum. The  line  of  coalescence  is 
elevated  above  the  surroundings, 
forming  the  raphe,  which  extends 
from  the  anus  to  the  meatus  urin- 


Development  of  the  External  Sexual  Organs 
in  the  Male  and  the  Female  from  the  in- 
different type :  A,  the  external  sexual  or- 
gans in  an  embryo  of  about  nine  \veeks, 
in  which  external  sexual  distinction  is 
not  yet  established,  and  the  cloaca  still 
exists;  B,  the  same  in  an  embryo  some- 
what more  advanced,  and  in  which,  with- 
out marked  sexual  distinction,  the  anus 
is  now  separated  from  the  urogenital 
aperture;  C,  the  same  in  an  embryo  of 
about  ten  weeks,  showing  the  female 
type ;  D,  the  same  in  a  male  embryo  some- 
what more  advanced ;  pc,  common  blas- 
tema of  penis  and  clitoris  or  genital  tuber- 
cle (to  the  right  of  these  letters  in  Fig.  A 
is  seen  the  umbilical  cord) ;  p,  penis ;  c, 
clitoris ;  d,  cloacal  opening ;  ug.  urogenital 
opening ;  a,  anus ;  to,  cutaneous  elevation 
which  becomes  the  labia  or  the  scrotum, 
genital  folds ;  I,  labium ;  «,  scrotum ;  co, 
caudal  or  coccygeal  elevation  (Ecker). 


arus. 


In  the  open  condition,  which  continues  until  the  eleventh  or  twelfth 
week,  the  external  genital  parts  are  alike  in  both  sexes,  and  resemble 
very  much  the  advanced  female  organs. 


PART  II. 

ANATOMY.1 

Division. — The  genitals  are  divided  into  two  groups :  the  external 
genitals,  which  are  organs  of  copulation ;  and  the  internal,  which  are 
organs  of  reproduction.  To  the  external  genitals  belong  the  mons 
Veneris,  the  vulva,  and  the  vagina;  to  the  internal,  the  uterus,  the 
Fallopian  tubes,  and  the  ovaries. 

THE  MONS  VENERIS. 

The  mons  Yeneris  (Venus'  mount)  is  the  lowest  part  of  the 
anterior  abdominal  wall,  and  the  only  part  of  the  genitals  that  is 
visible  when  the  woman  stands  on  her  feet.  It  has  somewhat  the 
shape  of  a  trapezoid,  and  is  limited  above  by  a  transverse  sulcus  that 
separates  it  from  the  hypogastric  region,  on  the  sides  by  the  inguinal 
folds,  and  below  it  is  continuous  with  the  labia  majora.  It  lies  in 
front  of  the  pubic  bones  and  the  lower  end  of  the  abdominal  muscles. 
It  has  a  convex  surface,  and  falls  gently  off  toward  the  surrounding 
parts.  It  consists  of  skin,  adipose  tissue,  with  many  interwoven 
fibrous  and  elastic  bands,  and  part  of  the  common  superficial  fascia. 
It  is  rich  in  nervous  fibrils.  The  skin  is  coarse,  has  many  sebaceous 
glands,  and  is  covered  by  a  growth  of  coarse  hair,  which  is  limited  by 
a  straight  or  convex  upper  line  (Fig.  28),  and  does  not  extend  up  to 
the  umbilicus,  as  in  man.  It  is  in  most  women  curly,  and  darker 
than  the  hair  of  the  head.  This  growth  appears  about  puberty. 

Function. — During  copulation  these  hairs  come  in  contact  with  the 
corresponding  growth  of  the  other  sex,  and  by  the  irritation  thus 

1  Those  who  wish  further  information  than  that  warranted  by  the  limits  of  this 
work  are  referred  to  the  excellent  articles  by  Henry  C.  Coe  in  the  System  of  Gyne- 
cology,  and  Ambrose  L.  Kannev,  Am.  Jour.  Obstetrics,  March,  April,  May,  June, 
1883. 

My  own  special  investigations  on  anatomical  questions  are  found  incorporated  in 
the  following  papers:  " Gastro-elytrotomy,"  N.  Y.  Med.  Jour.,  Oct.  and  Nov.,  1S7S; 
"The  Obstetric  Treatment  of  the  Perineum,"  Am.  Jour.  Obsl.,  April,  1880;  "Rest 
after  Delivery,"  ibid.,  Oct.,  1880;  "Laceration  of  the  Cervix  Uteri,"  Archives  of 
Medicine,  Oct.,  1881 ;  "  Additional  Remarks  on  Gastro-elytrotomy,  Am.  Jour.  Obat.. 
Jan.,  1883;  "Gartner's  Canals,"  N.  Y.  Med.  Jour.,  March  31,  1883;  and  "The  Im- 
proved Csesarean  Section,"  Am.  Jour.  Med.  Sciences,  May,  1888. 

35 


36 


DISEASES  OF  WOMEN. 


FIG.  28. 


caused  in  the  nerves  at  their  root  give  a  pleasurable  sensation.  The 
vessels  and  nerves  come  from  the  same  sources  as  those  of  the  vulva 
(see  below). 

THE  VULVA. 

The  vulva  (Fig.  28)  forms  and  surrounds  the  entrance  to  the  genital 
canal. 

The  following  organs  compose  it :  The  labia  majora,  with  the  four- 

chette;  the  labia  miuora,  with  the 
clitoris;  the  vestibule,  with  the  bulbs; 
the  fossa  navicularis;  and  the  vulvo- 
vaginal  glands. 

The  labia  majora  (larger  lips,  Fig. 
28,  1)  are  two  prominent  ridges,  one 
on  either  side  of  the  median  line.  A 
transverse  incision  shows  a  triangular 
cut  surface.  They  are  situated  in  front 
of  the  descending  ramus  of  the  pubes 
and  the  ascending  ramus  of  the 
ischium.  The  outer  surface  is  convex, 
of  darker  color  than  the  rest  of  the 
skin,  covered  with  a  continuation  of 
the  hair  on  the  mons  Veneris,  and  has 
numerous  and  large  sebaceous  and 
sudoriferous  glands.  The  inner  sur- 
face is  rose-colored,  and  forms  a  transi- 
tion from  skin  to  mucous  membrane, 
having  the  same  glands  as  the  outer 
surface,  and  even  a  few  downy  hairs. 
The  place  where  they  unite  anteriorly 
is  called  the  anterior  commissure,  and 
the  place  where  they  unite  behind  is 
called  the  posterior  commissure.  Here 
the  tissue  becomes  very  thin  by  the 
disappearance  of  the  fat  which  forms 
a  great  part  of  the  labia  majora.  Thus 
a  thin  fold  is  formed  called  the  four- 
chette.  Exceptionally,  the  fourchette  is  a  continuation  of  the  labia 
minora.  Its  lower  surface  consists  of  skin  which  has  a  dark  color, 
similar  to  that  of  the  external  surface  of  the  labia,  while  its  upper 
surface  is  pink,  and  looks  like  mucous  membrane.  In  the  adult  nul- 
liparous  woman  the  lower  edges  of  the  labia  majora  are  in  contact, 
cover  all  the  other  parts  of  the  vulva,  and  form  a  line  running  in  an 
antero-posterior  direction  and  called  rima  pudendL  In  the  new-born 
child,  in  whom  the  labia  majora  are  incompletely  developed,  the  labia 


Virginal  Vulva:  1,  labia  majora;  2, 
fourchette;" 3,  labia  minora;  4,  glans 
clitoridis ;  5,  meatus  urinarius ;  6,  ves- 
tibule ;  7,  entrance  to  the  vagina ;  8, 
hymen ;  9,  orifice  of  Bartholin's 
gland;  10,  anterior  commissure  of 
labia  majora  ;  11,  anus;  12,  blind  re- 
cess; 13,  fossa  navicularis;  14,  body 
of  clitoris  (modified  from  Tarnier). 


ANATOMY.  37 

miuora  protrude  between  them ;  and  when  by  childbirth  or  age  the 
labia  majora  become  flaccid  and  gape,  the  labia  minora,  the  entrance 
to  the  vagina,  and  even  part  of  that  canal  itself,  become  visible. 

The  structure  of  the  labia  majora  is  similar  to  that  of  the  rnons 
Veneris,  but  presents  some  peculiar  features.  Immediately  under 
the  skin  forming  the  outer  surface  is  found  a  layer  of  unstriped  mus- 
cular fibres,  which  has  been  called  ivoman's  dartos.  Under  the  dartos 
is  found  a  layer  of  adipose  and  connective  tissue,  and  under  that, 
again,  a  pear-shaped  sac  called  Broods  pouch,  or  the  pudendal  sac, 
attached  with  its  mouth  to  the  external  inguinal  ring,  and  extending 
with  its  broad  part  to  the  perineum,  with  the  superficial  fascia  of 
which  it  coalesces.  This  pouch  is  composed  of  elastic  fibres,  and 
contains  connective  tissue  and  fat.  Occasionally  the  prolongation  of 
the  peritoneum  called  the  canal  of  Nuck,  which  accompanies  the 
round  ligament  of  the  uterus,  is  found  in  it. 

Function. — The  labia  majora  protect  the  deeper  parts,  lead  the 
male  organ  to  them,  and  serve  as  buffers  during  coition. 

The  Labia  Minora  (small  lips)  or  Nymphcc. — These  are  two  small 
folds  of  skin  (Fig.  28,  3)  of  the  same  dark  color  as  the  outside  of  the 
labia  majora  and  the  fourchette.  They  present  a  triangular  surface 
when  cut  at  right  angles,  having  an  outer  and  an  inner  free  surface 
and  a  lower  edge.  At  the  anterior  end  they  separate  into  two  layers, 
the  lower  layer  fastening  itself  to  the  lower  surface  of  the  glans  cli- 
toridis,  forming  its  frenulum,  and  the  upper  passing  above  the  clitoris, 
forming  its  prepuce.  The  extension  backward  of  the  labia  minora  varies 
very  much.  In  some  women  they  go  back  to  the  middle  line,  so  as  to 
form  a  complete  ring  inside  of  that  formed  by  the  labia  majora.  In 
others  they  do  not  even  reach  the  level  of  the  meatus  urinarius.  In 
most  women  they  extend  back  about  halfway  between  the  clitoris  and 
the  posterior  commissure.  At  the  base  of  the  inside  is  a  more  or  less 
well-marked  whitish  line,  which  forms  the  limit  between  the  skin  and 
the  mucous  membrane.  Their  length  from  the  base  to  the  free  edge 
varies  likewise  very  much.  In  all  the  women  of  the  Bushmen  in  South 
Africa  and  in  some  of  the  Hottentot  women  they  hang  halfway  do\vn 
to  the  knees,  forming  the  so-called  Hottentot  apron  (Fig.  29). 

The  labia  minora  are  covered  with  several  layers  of  epidermic 
cells.  Beneath  the  epidermis  they  are  composed  of  connective  tissue, 
elastic  fibres,  and  smooth  muscular  fibres,  and  contain  large  venous 
plexuses.  They  have  no  hairs  nor  fat,  but  numerous  sebaceous 
glands  and  papillae  containing  bulb-shaped  terminal  organs  of  nerves. 

Function. — Their  physiological  significance  seems  to  be  to  ensure 
more  perfect  adaptation  and  to  act  as  an  irritant  for  the  nerves  of  the 
male  member  at  the  same  time  that  their  own  nerves  are  acted  on. 

The  Clitoris. — This  corresponds  to  the  penis  in  the  male,  but  the 
urethra  and  the  corpus  spongiosum  are  separated  from  it.  It  is  a 


38  DISEASES  OF   WOMEN. 

small  cylindrical  body  about  an  inch  long,  placed  in  the  median  line, 
below  the  anterior  commissure,  and  running  in  an  antero-posterior 
direction.  It  is  divided  into  the  glans,  the  body,  and  the  crura. 
The  glans  (Fig.  28,  4)  is  a  roundish  or  pointed  tubercle  which  forms 
the  end  of  the  clitoris.  It  is  the  only  part  of  it  that  is  visible,  and 
even  that  in  many  women  only  on  pulling  the  prepuce  back.  It  is  cov- 
ered with  mucous  membrane,  and  has  a  prepuce  and  frenulum  formed 
by  the  labia  minora.  The  body  (Fig.  28,  14)  is  surrounded  by  a 
fibrous  sheath,  and  consists  of  two  corpora  cavernosa  separated  by 
an  incomplete  pectiniform  septum.  These  corpora  cavernosa  consist 
of  fibrous  trabeculae,  elastic  fibres,  unstriped  muscular  fibres,  and 
venous  plexuses,  with  numerous  anastomoses.  The  body  is  attached  to 
the  anterior  surface  of  the  symphysis  pubis  by  the  suspensory  liga- 
ment. Arrived  at  the  pubic  arch,  the  body  separates  into  two  ci'ura 
(Fig.  30),  small  fibrous  cylinders  attached  to  the  rami  of  the  pubes 

FIG.  30. 


Front  View  of  the  Perineal  Septum,  showing  entire  clitoris :  1,  glans ;  2,  suspensory  ligament ; 
3,  crura  of  clitoris;  4,  subpubic  ligament;  5,  dorsal  vein  of  clitoris;  6,  perineal  septum 
(Savage's  name  for  the  deep  perineal  fascia  or  triangular  ligament) ;  7,  superficial  trans- 
verse muscle ;  u,  meatus  urinarius ;  v,  vagina ;  P,  site  of  perineal  body  (Savage). 

and  the  ischium.  They  are  covered  by  the  erector  clitoridis  muscle, 
which  has  its  origin  on  the  tuberosity  of  the  ischium  and  is  inserted 
on  the  crura,  where  they  unite. 

Blood-vessels. — The  clitoris  is  an  erectile  organ,  with  helicine  (spi- 
ral) arteries  and  numerous  anastomosing  veins.  It  receives  the  two 
end  branches  of  the  internal  pudic  artery,  the  dorsal  artery,  running 
on  the  upper  surface,  and  the  artery  of  ike  corpus  cavernosum  in  the 
depth  of  that  body.  The  veins  go  to  the  dorsal  vein,  running  in  the 
middle  line  between  the  two  arteries,  and  ending  in  the  pudic  plexus, 


ANATOMY.  39 

which  surrounds  the  upper  part  of  the  urethra.  Those  of  the  glans 
communicate  with  the  bulbus  vaginae. 

The  lymphatics  go  to  the  superficial  inguinal  glands. 

Nerves. — The  clitoris  has  a  rich  nerve-supply  (Fig.  31)  from  the 
dorsal  nerve  of  the  clitoris,  a  branch  of  the  pudic  nerve,  and  from  the 
sympathetic,  which  form  a  kind  of  nervous  sheath  round  the  glans, 
with  a  peculiar  kind  of  end-bulbs  called  genital  corpuscles. 

Function. — The  clitoris  is  the  chief  seat  of  sexual  excitement  in 
women,  and  therefore  often  the  object  of  masturbation.  During 
coition  it  is  enlarged,  arched,  and  the  glans  is  pressed  against  the 
dorsurn  penis. 

The  vestibule  (Fig.  28,  6)  is  the  triangular  space  between  the  clit- 
oris, the  labia  minora,  and  the  entrance  to  the  vagina.  It  corre- 
sponds to  the  urogenital  sinus  of  the  embryo.  In  the  middle  line  we 
have  the  meatus  urinarius,  which  in  most  women  forms  a  small  isos- 
celes triangle,  with  the  base  turned  back  toward  the  vaginal  entrance, 
from  which  it  is  about  a  quarter  of  an  inch  distant,  while  the  distance 
from  the  clitoris  is  about  three  times  as  long.  On  either  side  of  this 
opening,  just  inside  of  the  labia  minora,  is  a  deep  blind  recess  (Fig. 
28, 12).  As  these  recesses  are  always  plainly  visible,  and  the  urethral 
opening  sometimes  does  not  appear,  the  former  become  valuable  land- 
marks in  catheterizatiou  by  eyesight.  By  placing  the  catheter  just 
midway  between  the  two  blind  sacs  we  cannot  miss  the  urethra.  In 
catheterization  under  cover  the  tip  of  the  forefinger  is  introduced  into 
the  vagina,  the  bulb  toward  the  urethra ;  the  catheter  is  slid  along 
the  median  line  of  the  finger  until  it  reaches  the  vestibule,  and  then 
raised  a  quarter  of  an  inch. 

There  are  many  other  smaller  depressions,  both  in  the  recesses  and 
in  other  parts  of  the  vestibule,  which  are  the  openings  of  compound 
racemose  glands  (glandulce  vestibulares  minores]  that  secrete  a  mucous 
fluid.  Sebaceous  glands  are  absent. 

The  vestibulo-vaginal  bulbs  (Fig.  32)  are  two  leech-shaped  organs, 
one  on  either  side  of  the  vestibule  and  the  entrance  to  the  vagina. 
Together  they  are  equivalent  to  the  bulb  of  the  urethra  in  the  male. 
The  posterior  end  is  round,  and  reaches  back  toward  the  posterior  part 
of  the  vaginal  orifice,  where  it  is  in  contact  with  the  vulvo-vaginal 
gland,  and  partly  covers  it.  The  anterior  end  is  thinner,  and  nearly 
reaches  the  clitoris.  It  lies  under  the  mucous  membrane  and  the 
superficial  fascia  of  the  perineum,  and  inside  of  the  sphincter  vaginae 
muscle.  It  consists  of  a  fibrous  sheath,  and  inside  of  that  numerous 
veins  from  the  internal  pudic,  complicated  venous  plexuses,  some 
nerves,  mostly  belonging  to  the  sympathetic  system,  unstriped  mus- 
cular fibres,  and  connective  tissue.  The  veins  have  numerous  com- 
munications with  those  of  the  surrounding  parts.  Near  the  anterior 
end  of  the  bulbs  they  go  from  one  side  to  another,  uniting  the  two 


40  DISEASES  OF  WOMEN. 

both  behind  and  in  front  of  the  meatus  urinarius,  forming  the  pars 
intermedia,  and  from  here  they  communicate  with  the  corpora  cav- 
ernosa  of  the  clitoris. 

The  fossa  navicularis  is  that  part  of  the  vulva  situated  between  the 
vaginal  entrance  in  front  and  the  fourchette  behind,  and  limited  on 
the  sides  by  the  labia  majora  and  above  by  the  perineal  body.  It 

FIG.  32. 


Front  View  of  the  External  Erectile  Organs :  a,  vestibule- vaginal  bulb ;  6,  sphincter  vaginae 
muscle;  ce,  pars  intermedia;  /,  glans  clitoridis;  g,  connecting  veins;  h,  dorsal  vein  of 
the  clitoris;  k,  veins  passing  behind  the  pubes;  I,  obturator  vein  (Kobelt). 

The  bulbs  are  over-distended  with  injection-fluid  and  reach  too  far  back. 

does  not  exist  as  a  hollow  when  the  labia  majora  are  in  contact.  It 
is  first  formed,  and  gets  its  boat-shape  when  they  are  separated  from 
each  other.  On  stretching  them  from  side  to  side  we  see  the  pos- 
terior commissure  advance  until  it  reaches  the  level  of  the  posterior 
border  of  the  entrance  to  the  vagina.  Thus  a  fold  and  a  hollow  are 
formed.  The  fold  is  the  fourchette ;  the  hollow  is  the  fossa  navicularis. 

In  virgins  the  fourchette  projects  a  little  forward,  even  without 
stretching,  but  in  women  who  have  had  frequent  intercourse  it  becomes 
so  lax  that  the  projection  is  lost  or  much  diminished.  During  child- 
birth it  is  often  torn.  The  lining  membrane  of  this  fossa  seems  to 
make  a  transition  from  skin  to  mucous  membrane. 

Function. — The  vestibule  and  fossa  navicularis  form  together  one 
cavity,  which,  lying  deeper  (i.  e.  higher  up  in  the  erect  posture)  than 
the  surroundings,  and  being  coniform,  in  connection  with  the  larger 
space  formed  by  the  labia  majora,  lead  the  entering  member  of  copu- 
lation to  the  entrance  of  the  vagina. 

The  vulvo-vaginal  glands,  or  Bartholin's  glands  (Fig.  33,  6),  are 
two  small  oval  bodies,  of  the  size  of  a  beau  to  that  of  an  almond,  situ- 
ated one  on  either  side  of  the  entrance  to  the  vagina  close'  up  to  the 
posterior  end  of  the  vestibulo-vaginal  bulb,  in  front  of  the  superficial 


FIG.  31. 


The  Nerves  of  the  Pelvis  :  A,  abdominal  aorta ;  B.  lumbar  vertebrae  with  intervertebral  disks . 
C,  the  right  portion  of  the  sacrum  sawn  after  removal  of  os  innominatum  ;  D,  ureter;  E, 
pyriformis  muscle  cut  at  its  exit  from  the  pelvic  cavity  ;  F,  the  curve  of  the  rectum,  cor- 
responding to  the  anterior  surface  of  the  sacrum ;  H,  virginal  uterus  feebly  developed ; 
K,  right  ovary  displaced  somewhat  upward;  L.  bladder;  M,  levator  ani  muscle,  cut  in 
part:  N,  ischio-cavernosus  muscle;  O,  corpus  cavernosum  clitoridis,  joining  on  the  other 
side  the  clitoris,  covered  with  nerve-filaments:  F,  symphysis  pubis  (the  whole  body 
being  inclined  forward,  it  has  become  horizontal);  T,  fimbriated  end  of  Fallopian  tube; 
1,  Lumbar  nervea,  passing  out  of  the  intervertebral  foramina  to  form  the  lumbar  plexus ;  the 
lower  lumbar  and  the  upper  sacral  nerves  joining  to  form  the  sacral  plexus  in  front  of  the 
pyriformis  muscle ;  3,  gluteal  nerves  cut ;  the  pudic  nerve  springing  by  several  roots  from 
the  plexus  formed  by  the  lower  sacral  nerves;  5,  fine  twigs  passing  from  the  pudic  nerve 
to  the  ischio-cavernosus  muscle;  the  main  trunk  goes  under  the  symphyris,  and  ends  as 
the  dorsal  nerve  of  the  clitoris  (21) ;  6,  branches  of  communication  which  carry  sympathetic 
twigs  to  the  spinal  nerves  and  spinal  twigs  to  the  hypogastric  plexus  of  the  sympathetic; 
7,  principal  trunk  of  the  sympathetic  in  front  of  the  lumbar  vertebra;  8,  continuation  of 
the  sympathetic  in  front  of  the  sacrum  ;  9,  aortic  plexus ;  10,  hemorrhoidnl  plexus,  following 
the  arteries  of  the  same  name ;  11.  superior  hypogastric  plexus,  or  ttio-hypogastric  plexus, 
which  receives  many  spinal  and  sympathetic  branches  ;  12,  inferior  hypnqastric  plexus,  com- 
municating with  13,  anterior  sacral  plexus,  made  up  of  spinal  and  sympathetic  branches ; 
14,  from  the  many  ganglia  placed  in  this  plexus  it  has  a  network  appearance  ;  lo,  inferior 
rectal  twigs,  which  pass  down  even  to  the  sphincter,  where  they  form  a  network  covered 
by  the  levator  ani ;  16,  vaginal  plexus;  17.  that  part  of  the  inferior  hypogastric  plexus  in 
the  shape  of  a  fine  network  at  the  upper  end  of  the  vagina  gives  branches  to  the  bladder, 
the  Fallopian  tube,  and  the  clitoris;  18.  nerve-twigs  which  run  on  the  side  wall  of  the 
uterus  (giving  branches  to  it)  upward  to  the  Fallopian  tube  and  ovary,  where  they  join  the 
nerves  following  the  ovarian  artery,  which  correspond  to  the  spermatic  plexus  in  man; 
19,  vesical  nerves;  20,  uterine  plexus;  21,  dorsal  nerve  of  clitoris,  which  joins  with  the  cav- 
ernous plexus  of  the  clitoris  from  the  sympathetic  to  the  glans  clitoridis  (Rydygier). 


ANATOMY. 


41 


transversus  perimei  muscle,  and  between  the  posterior  third  of  the 

side  of  the  vaginal  entrance  and  the  erector  clitoridis  muscle.     They 

lie  between  the  two  layers  of  the  deep 

perineal  fascia,  or  sometimes  under  (/.  e., 

above  in  the  erect  posture)  the  deep  layer.1 

They  are  compound  racemose  glands,  se- 

creting   a    mucous    fluid,  just    like    the 

smaller  glands  of  the  vestibule,  and  are 

sometimes    called    glandulce    vestibulares 

majores.     Their  excretory  duct  opens  with 

a  minute  aperture  just  in  front  and  out- 

side of  the  hymen,  on  the  inside  of  the 

labia  majora,  or  labia  minora  if  these  ex- 

tend so  far  back.     They  contribute  to  the 

lubrication  of  the  vulva,  especially  when 

pressed  upon  by  the  surrounding  muscles 

during  sexual  excitement. 

In  the  erect  posture  the  vulva  is  hidden 
between  the  thighs.  When  not  artificially 
spread  out,  the  two  lateral  halves  are  in 
contact  in  the  normal  adult  woman. 

The  vulva  receives  its  arteries  from  the 
superficial  perineal  branch  of  the  internal 
pudic  and  the  external  pudic  arteries  com- 
ing from  the  femoral.  The  veins  accom- 
pany the  arteries.  On  account  of  the  free 
communications  between  themselves  and  with  those  of  the  pelvis 
even  a  small  wound  of  the  vulva,  especially  when  during  pregnancy 
they  swell,  may  cause  dangerous  or  even  fatal  venous  hemorrhage. 
The  lymphatics  open  into  the  superficial  inguinal  glands,  which  are 
in  communication  with  the  deep  inguinal  glands  and  external  iliac 
glands.  The  nerves  come  from  the  superficial  perinea!  nerve,  which 
is  a  branch  of  the  pudic,  the  inferior  pudendal  nerve,  which  is  a 
branch  of  the  small  sciatic  nerve,  and  from  the  pelvic,  or  inferior 
hypogastric,  plexus  of  the  sympathetic  nerve. 

Special  features  of  the  vessels  and  nerves  of  the  clitoris  and  the  bulbs 
of  the  vestibule  have  been  treated  under  the  descriptions  of  those  organs. 

THE  VAGINA. 

Until  within  a  few  years  all  descriptions  and  drawings  of  the 
vagina  gave  a  very  erroneous  idea  of  this  organ.  It  is  a  slit  in  the 
pelvic  floor  (Fig.  34,  A),  having  a  slanting  direction  from  above  and 

1  Ambrose  L.  Ranney  found  in  every  case  Bartholin's  glands  lying  posterior  to 
triangular  ligament  ("The  Female  Perineum,"  N.  Y.  Med.  Jour.,  July-August, 
1882,  vol.  xxxvi.  p.  45). 


Vulvo-vaginal  Gland.  Thelabium 
majus  and  minus,  the  sphincter 
vaginae  muscle,  and  the  bulb 
have  been  partly  removed  on  the 
right  side  in  order  to  expose  the 
gland  :  A  A',  section  of  labium 
majus  and  minus;  B,  gland;  C, 
excretory  duct;  (7,  stylet  intro- 
duced into  the  duct ;  D,  glandu- 
lar end  of  duct ;  E,  free  end  of 
duct :  F,  section  of  bulb ;  G,  as- 
cending ramus  of  ischium  (Hu- 
guier). 


42 


DISEASES  OF  WOMEN. 


behind  downward  and  forward,  at  an  angle  of  60°  with  the  horizon, 
situated  between  the  bladder  and  the  urethra  in  front  and  the  rectum 


FIG.  34. 


Sagittal  Section  of  Pelvis  (Waldeyer) :  a,  symphysis  pubis ;  6,  bladder ;  c,  small  intestine ;  d, 
large  intestine;  e,  anus ;  /,  perineal  oody ;  g,  vulva ;  h,  vagina ;  i,  uterus. 

behind,  and  extending  from  the  vulva  below  to  the  uterus  above.  It 
has  a  slight  curve  with  the  concavity  forward,  corresponding  to  the 
shape  of  the  male  member  when  in  erection — a  curve  which  is  much 
increased  during  parturition,  when  the  child  rounds  the  symphysis 
pubis.  When  distended  it  has  the  shape  of  a  truncated  cone  with 
the  apex  at  the  vulva  and  the  base  at  the  uterus ;  but  when  not  dis- 
tended it  is  folded  together  in  such  a  way  that  the  slit  on  a  cross- 
section  has  somewhat  the  shape  of  the  letter  H,  the  anterior  and 
posterior  wall  being  in  contact  in  the  middle,  and  each  side  wall  being 
folded  against  itself  at  the  ends  (Fig.  35,  va).  At  the  lower  end  it 
dips  into  the  vulva,  forming  the  hymen,  in  the  same  way  as  at  the 
upper  end  the  uterus  dips  into  the  vagina,  forming  the  vaginal  por- 
tion. At  the  upper  end  it  forms  a  cup,  adapting  itself  closely  to  the 
vaginal  portion  of  the  uterus,  as  does  the  cup  to  the  ball  of  the  toy 
called  "bilboquet"  or  "cup  and  ball."  The  upper,  broader  end  is 
called  the  roof  or  fornix,  and  in  its  adaptation  to  the  vaginal  portion 
it  forms  a  shallow  pouch  in  front  and  a  much  deeper  behind,  united  by 
side  pouches,  forming  an  even  transition  from  one  to  the  other.  The 
lower  end,  when  we  remove  the  hymen  (which  will  be  considered  later), 
forms  a  circular  opening,  surrounded  by  the  constrictor  vaginae  muscle. 


ANATOMY. 


43 


In  olden  times  authors,  just  as  the  laity  often  do  yet,  comprised 
the  whole  parturient  canal  under  the  term  "  womb  "  or  uterus.  Now 
the  profession  has  learned  to  distinguish  the  womb  from  the  vagina, 
but  the  latter  is  yet  in  obstetrical  and  gynecological  language  fre- 
quently confounded  with  the  vulva.  We  must,  therefore,  expressly 
call  attention  to  the  limits  between  these  two  parts  of  the  parturient 
canal,  and  the  difference  between  the  two  openings  at  its  beginning. 
The  entrance  to  the  vulva  is  formed  by  the  rima  pudendi,  a  slit  in 
the  skin  running  in  a  straight  line,  in 
an  antero-posterior  direction ;  the  en- 
trance to  the  vagina  lies  an  inch  or  two 
deeper,  is  circular,  surrounded  by  mu- 
cous membrane  and  muscles,  and  is 
marked  by  the  hymen  or  its  remnants. 

The  size  of  the  vagina  varies  enor- 
mously in  different  individuals  and  dif- 
ferent conditions.  In  the  adult  virgin 
the  anterior  wall  is  about  2  inches,  the 
posterior  about  2J  inches  long,  and  the 
width  near  the  upper  end  about  1J 
inches.  By  coition,  and  especially  child- 
birth, these  dimensions  are  much  in- 
creased. During  copulation  it  has  the 
size  of  the  body  that  distends  it.  Dur- 
ing pregnancy  great  proliferation  of  tis- 
sue, swelling  of  veins,  and  serous  infil- 
tration take  place,  so  that  at  the  time 
of  delivery  the  canal  not  only  is  wide 
enough  to  let  the  child  pass,  but  be- 
comes so  elongated  that  it  can  accom- 
pany the  child  far  beyond  the  limits  of  the  outlet  of  the  bony  pelvis. 

The  vagina  is  composed  (Figs.  36,  37)  of  an  outer  sheath  of  con- 
nective tissue,  containing  fat,  a  muscular  layer  with  longitudinal  and 
transverse  fibres,  and  a  mucous  membrane  with  flat  epithelium.  The 
muscular  fibres  can  be  followed  to  the  posterior  surface  of  the  pubic 
bone  and  the  anterior  surface  of  the  sacro-iliac  articulation  (Rouget). 
In  the  perineal  region  the  muscle-fibres  reach  the  bone  between  the 
two  layers  of  the  triangular  ligament.  The  mucous  membrane  forms 
on  the  anterior  wall  a  longitudinal  ridge  in  or  near  the  median  line, 
from  which  folds,  so-called  rugce,  go  out  to  the  sides,  like  the  teeth 
of  a  comb;  a  similar  but  less  distinct  formation  is  found  on  the 
posterior  wall.  They  are  called  the  anterior  and  posterior  columns. 
The  anterior  often  ends  below  in  a  round  protuberance,  called  the 
tubercle  of  the  vagina,  which  is  situated  immediately  behind  the 
meatus  urinarius.  Often  the  anterior  column  is  divided  by  a  lou- 


Horizontal  Section  of  the  Soft  Parts 
in  the  Inferior  Strait  of  the  Pelvis 
(Henle) :  Va,  vagina  :  Ur,  urethra  ; 
R,  rectum  ;  L,  levator  ani. 


44 


DISEASES  OF  WOMEN. 


gitudinal  furrow  into  two  halves.  The  rugse  are  covered  witli  micro- 
scopical papillae.  The  columns  and  the  rugae  disappear  in  the  upper 
part  of  the  vagina.  They  are  organs  of  sexual  excitement,  and  con- 


FIG.  36. 


FIG.  36.— Longitudinal  Section  of  the  Posterior  Wall  of  the  Vagina  of  a  girl  twenty-four  years 

old. 

FIG.  37. — Transverse  Section  of  the  Same  (Breisky) :  a,  mucous  membrane ;  b,  muscular  layer, 
with  a,  circular,  and  ^,  longitudinal  fibres;  c,  fibrous  layer  containing  adipose  tissue. 

tribute  probably  to  the  enlargement  of  the  vagina  during  pregnancy  and 
childbirth.  After  the  latter  they  are  much  less  prominent  or  disappear 
entirely.  The  presence  of  glands  in  the  mucous  membrane  is  disputed.1 

The  vagina  possesses  the  power  of  absorption.  This  faculty  is  in- 
creased in  pregnant,  puerperal,  and  feverish  women.2 

The  vagina  has  a  rich  vascular  supply.  The  arteries  (Fig.  38)  come 
from  the  vaginal,  the  uterine,  the  vesical,  and  the  internal  pudic,  which 
all  are  branches  of  the  anterior  division  of  the  internal  iliac. 

1  In  a  woman  in  the  fifth  month  of  pregnancy  I  have  seen  the  whole  vagina  red 
and  full  of  openings  like  a  tonsil,  out  of  which  a  solid  yellowish  discharge  could  be 
pressed.     I  do  not  see  what  these  openings  could  have  been  except  entrances  to 
glandular  follicles. 

2  Coen  and  Levi :  Centralblatt  fiir  Gynakologie,  1894,  No.  49,  p.  1261. 


—  o 
5  3  ">,2  x  5  v" «'  /-, 

^.S*®!  §  5'^5  P 
^lll^H- 


5s»'»s7l§ 


i-H-^ll^B 


ANATOMY. 


45 


The  veins  form  a  dense  network  (Fig.  39),  and  communicate  with 
those  of  the  vulva,  the  bladder,  the  rectum,  the  uterus,  and  the  broad 
ligament.  Finally,  the  blood  is  carried  to  the  internal  iliac  veins. 

The  lymphatics  from  the  lower  fourth  go  to  the  superficial  inguinal 


.  39. 


The  Venous  Plexuses  of  the  Vagina  and  the  Vulva,  as  seen  in  mesial  section  (Savage) :  B, 
bladder  partially  inflated ;  b,  ureter ;  V.  vagina  ;  P,  section  of  pubes ;  R,  rectum ;  C,  clitoris ; 
1,  bulb;  2,  its  urethral  process;  3,  lower  efferent  veins ;  4,  dorsal  vein  of  the  clitoris;  5, 
urethral  venous  plexus:  6,  commencement  of  vaginal  venous  plexus;  7,  8,  9, 10,  sciatic 
and  gluteal  veins;  il,  uterine  veins;  12,  obturator  vein;  13,  internal  iliac  vein;  o,  pyri- 
forrnis  muscle  ;  b,  greater  sacro-sciatic  ligament ;  c,  levator  ani  and  coccygeus  muscles ; 
d,  os  coccygis ;  e,  suspensory  ligament  of  clitoris ;  F,  vulvo-vaginal  gland ;  ggg  roots  of 
sacral  plexus  of  nerves. 

glands,  like  those  from  the  vulva ;  those  from  the  upper  three-fourths 
go  to  the  internal  iliac  glands,  and  perhaps  the  obturator  glands, 
which  again  communicate  with  the  inguinal  glands. 

The  nerves  (Fig.  31)  come  from  the  sympathetic,  and  form  a  vrtf/inal 
plexus  on  either  side  of  the  vagina,  communicating  with  the  inferior 
hypogastric.  Their  final  fibrillse  terminate  in  end-bulbs. 

Function. — The  vagina  has  a  double  physiological  function.  Dur- 
ing copulation  it  receives  the  penis,  and  during  parturition  it  helps 
move  the  child  forward  along  the  curve  of  Cams.  The  vagina  can 
become  distended  independently  of  the  introduction  of  any  distending 
solid  body  or  air-pressure,  which  works  when  the  patient  is  examined 
in  the  knee-chest  or  Sims's  position.  This  must  be  due  to  the  con- 
traction of  the  muscular  fibres  that  are  attached  to  the  pelvic  bones. 
I  have  often  found  this  ballooning  during  examinations  with  a  single 


46 


DISEASES  OF   WOMEN. 


finger  with  the  patient  lying  on  her  back,  and  in  nullipane  with  a 
tight  vaginal  entrance.     The  same  applies  to  the  rectum. 

THE  HYMEN. 

The  hymen  begins,  as  we  have  seen  in  the  history  of  the  develop- 
ment, as  a  protuberance  from  the  posterior  wall  of  the  vagina.  It  is 
a  fold  of  the  mucous  membrane  containing  elastic  fibres,  blood-vessels, 
lymph -vessels,  nerves,  and  sometimes  smooth  muscular  fibres.  It 
closes  the  vagina  more  or  less  completely,  and  varies  much  in  shape, 
but  in  most  cases  it  is  more  developed  behind  than  in  front.  The 
most  common  shape,  especially  in  childhood,  is  that  of  a  strip  of 
tissue  bent  so  as  to  form  two  lateral  halves  touching  one  another  in  a 
straight  middle  line  (Fig.  40).  In  other  cases  it  forms  a  ring  with  a 


FIG.  41. 


FIG.  40. 


Hymen  with  Linear  Opening  (Tardieu). 


Annular  Hymen  (Tardieu). 


round  opening  (Fig.  41).  In  others,  again,  it  has  the  shape  of  a 
crescent  (Fig.  42).  Often  the  border  is  indented  (Fig.  43),  a  form 
that  is  easily  distinguished  from  a  lacerated  hymen  by  the  softness  of 
the  tissues,  the  absence  of  cicatrices,  the  round  contour  of  the  tongues, 
and,  above  all,  by  the  decided  resistance  that  is  felt  in  trying  to  enter 
the  finger.  Sometimes  the  hymen  is  only  represented  by  a  low  circu- 
lar or  crescentic  ridge.  The  upper  surface  shows  a  continuation  of 
the  ruga?  of  the  vagina,  of  which  it  only  forms  the  lowest,  thinned 
part,  somewhat  in  the  manner  of  the  relation  between  the  fourchette 
and  the  posterior  end  of  the  labia  majora. 

The  hymen  is,  as  a  rule,  torn  by  the  first  successful  coition,  into 
two  or  three,  rarely  a  greater  number  of  flaps,  but  there  is  no  loss 
of  substance.  By  putting  the  flaps  in  contact  we  can  reproduce  its 
original  shape.  In  childbirth,  on  the  contrary,  it  suffers  so  much 


ANATOMY. 


47 


that   only  three   or  four   roundish  prominences  are  left  of  it,  the 
so-called  earunoulce  myrtiformes. 

In  a  strictly  intact  vulva  considerable  resistance  is  felt,  and  pain  is 
caused  by  the  examining  finger,  be  it  at  the  opening  of  the  hymen  or 
at  its  base,  where  it  joins  the  rest  of  the  vagina.  An  easy  accessi- 


FIQ.  42. 


FIG.  43. 


Crescent-shaped  Hymen  (Tardieu). 


Indented  Hymen. 


bility  of  the  vagina  without  laceration  of  the  hymen  is  due  to  a 
gradual  dilatation  by  a  comparatively  small  body.  It  must  be  borne 
in  mind  that  this  not  always  means  masturbation.  It  may  as  well  be 
the  result  of  careful  gynecological  treatment,  while  a  careless  examina- 
tion may  rupture  the  membrane,  producing  a  result  similar  to  that 
of  coition. 

THE  UTERUS. 

The  uterus  (Fig.  44)  is  a  hollow  body  with  thick  muscular  walls 
situated  between  the  vagina  below  and  the  small  intestines  above,  the 
bladder  in  front,  and  the  rectum  behind.  It  has  somewhat  the  shape 
of  a  flattened  pear,  and  may  be  divided  into  two  parts,  called  the  neck, 
or  cervix  and  the  body,  or  corpus.  A  subdivision  of  the  neck  is  the 
vaginal  portion  (Fig.  44,  A,  a),  which  dips  down  into  the  vagina ;  and 
a  subdivision  of  the  body  is  the  fundus  (Fig.  44,  C,  /),  which  lies 
above  the  entrance  of  the  Fallopian  tubes.  The  neck  is  cylindrical 
or  rather  barrel-shaped,  being  thicker  in  the  middle  than  at  the  ends, 
and  the  line  of  demarkation  between  it  and  the  body  is  marked  out- 
side, on  its  anterior  surface,  by  the  fold  formed  by  the  peritoneum 
when  from  the  uterus  it  passes  over  on  the  bladder. 


48 


DISEASES  OF   WOMEN. 


The  vaginal  portion  or  infravaginal  part  of  the  cervix  forms  a 
rounded  cone  nearly  one-half  inch  high,  on  the  top  of  which  is 
found  a  transverse  slit  measuring  about  one-quarter  of  an  inch  from 
side  to  side,  and  called  the  os  externum,  os  tincce  (i.  e.  the  mouth  of  a 
tench),  or  simply  the  os  uteri.  If  we  imagine  this  opening  prolonged 
so  as  to  divide  the  cervical  portion  into  two  halves,  the  anterior  is 
called  the  anterior  lip,  and  the  posterior  the  posterior  lip — a  condi- 
tion that  often  is  produced  by  childbirth,  but  then  is  pathological. 

FIG.  44. 


Virgin  Uterus,  natural  size  (Sappey) :  A,  front  view :  the  appendages  and  the  vagina  are  cut 
away  ;  a,  vaginal  portion  of  cervix  ;  b,  isthmus ;  c,  body. 

B,  the  same  in  vertical  mesial  section:  a,  anterior  surface;  the  letter  is  placed  a  little  above 

the  bottom  of  the  vesico-uterine  pouch. 

C,  the  same  with  cavity  exposed  by  coronal  section :  e,  qs  externum ;  d,  os  internum ;  /, 

fundus,  the  letter  placed  just  above  utenne  opening  of  Fallopian  tube. 

The  anterior  lip  dips  lower  down  than  the  posterior,  but  the  pouch 
formed  by  the  vagina  being  much  deeper  behind  than  in  front  (Fig. 
44,  B)  the  posterior  lip  goes  much  higher  up,  so  that  it  is  longer  than 
the  anterior.  The  vaginal  portion  is  covered  with  a  smooth  mucous 
membrane  with  flat  epithelium,  like  that  of  the  vagina. 

The  supravaginal  part  of  the  neck  is  about  f  inch  long,  and  is 
bound  with  rather  loose  connective  tissue  to  the  bladder  in  front,  and 
on  the  sides  to  the  mass  forming  the  base  of  the  broad  ligaments  of 
the  uterus,  and  called  the  parametrium.  Behind,  it  is  free,  being 
separated  from  the  rectum  by  a  part  of  the  peritoneal  cavity  called 
Douglas's  pouch. 

The  body  of  the  uterus,  in  the  more  restricted  sense  of  the  word, 
is  triangular.  It  forms  a  flattened  truncated  cone,  with  the  end 
turned  down  to  the  cervix  and  the  base  up  to  the  fundus.  The  sides 


ANATOMY.  49 

are  a  little  convex  (Fig.  44,  A).  The  anterior  surface  is  convex  from 
side  to  side,  and  straight  or  slightly  concave  from  above  downward. 
The  posterior  surface  is  strongly  convex  in  all  directions.  The  fun- 
dus  is  moderately  convex  from  side  to  side,  and  much  more  so  from 
the  anterior  to  the  posterior  surface  (Fig.  44,  B  and  (7). 

The  interior  of  the  womb  contains  a  cavity  (Fig.  44,  B  and  C),  the 
anterior  and  posterior  walls  of  which  are  in  contact.  It  is  2  inches  long 
in  the  nulliparous  woman,  and  is  divided  into  three  parts,  the  cervical 
canal,  the  isthmus,  and  the  cavity  of  the  body.  The  cervical  canal  is 
about  1  inch  long,  is  spindle-shaped,  and  on  the  anterior  and  posterior 
wall  there  is  found  a  longitudinal  ridge  from  which  branches  go  out- 
ward and  upward,  separated  by  deep  pouches.  The  whole  formation 
is  called  arbor  vitce,  palmce  plicatce,  or  plicce  palmatce.  The  isthmus, 
or  os  internum,  is  the  narrowest  part  of  the  cavity,  nearly  cylindrical, 
about  ^  inch  long  and  -|  inch  in  diameter.  The  median  ridge  of  the 
arbor  vitce  extends  to  its  upper  end.  The  cavity  of  the  body  is  tri- 
angular, with  curved  sides  bulging  into  the  cavity  and  smooth  sur- 
faces. At  the  two  upper  angles  are  found  the  uterine  apertures  of 
the  Fallopian  tubes. 

The  wall  is  about  -|  of  an  inch  thick  in  the  thickest  parts,  which 
are  the  middle  of  the  edges  of  the  body,  the  middle  of  the  fundus, 
and  the  middle  of  the  cervix.  It  is  thinnest  at  the  entrances  to  the 
Fallopian  tubes  and  at  the  external  os. 

The  size  of  the  womb  increases  somewhat  by  sexual  intercourse, 
and  still  more  by  childbirth.  The  length  measures  in  virgins  2 
to  2^  inches,  in  nulliparse  2  to  2|  inches,  in  multipart  2^  to  3 
inches.  The  width  on  the  level  of  the  Fallopian  tubes,  the  broadest 
part,  is  in  virgins  1^  to  If,  in  nulliparse  the  same,  in  multipart  ]|-  to 
2  inches.  The  thickness  is  about  the  same  in  all  three  classes,  varying 
from  -|  of  an  inch  to  1^  inches. 

The  cervix  is  about  1^  inches  from  side  to  side  in  the  middle,  and 
a  little  less  at  the  ends. 

The  body  is  only  a  little  longer  than  the  neck  in  nulliparee ;  in 
those  who  have  borne  children  it  becomes  three-fifths  or  two-thirds 
of  the  length  of  the  whole  organ. 

The  wall  is  composed  of  three  layers — a  serous,  a  muscular,  and  a 
mucous.  The  serous  coat  is  formed  by  the  peritoneum,  and  does  not 
cover  the  anterior  surface  and  the  sides  of  the  cervix. 

The  muscular  part  of  the  wall  may  be  divided  into  three  layers, 
which  become  distinct  during  pregnancy  :  an  outer  longitudinal  layer, 
which  sends  prolongations  into  the  round  and  the  ovarian  ligaments, 
the  tubes,  and  the  sacro-uterine  ligaments ;  a  middle  layer  of  interlacing 
longitudinal  and  transverse  fibres,  which  is  in  connection  with  the 
muscular  coat  of  the  vagina ;  and  an  internal  transverse  layer,  which 
is  especially  developed  in  what  was  formerly  the  two  horns,  and  near 

4 


50 


DISEASES  OF   WOMEN. 


the  internal  os,  in  which  latter  place  it  forms  a  sphincter.  It  enters 
also  the  folds  of  the  plicae  palmatse.  The  middle  layer  is  the  thickest 
and  contains  the  vessels. 


FIG.  45. 


Vertical  Section  through  the  Mucous  Membrane  of  the  Human  Uterus  (Turner) :  e,  columnar 
epithelium;  the  cilia  are  not  represented ;  0,17,  utricular  glands;  ct,  interglandular  con- 
nective tissue  ;  v,v,  blood-vessels ;  mm,  muscular  layer. 

The  mucous  membrane  (Fig.  45)  lines  the  whole  cavity.  In  the  body 
it  is  thin  and  intimately  connected  with  the  muscular  layer,  bundles 
of  the  muscles  and  connective  tissue  extending  from  one  to  the  other. 
When  fresh  it  is  pink.  It  consists  of  fine  threads  of  connective  tissue 
and  round  or  oblong  cells  (Figs.  46  and  47),  and  is  perforated  by  numer- 
ous tubes,  composed  of  a  basement  membrane  and  a  layer  of  ciliated  col- 
umnar epithelium,  and  called  the  utricular  glands.  They  have  a  general 
direction  parallel  to  one  another,  but  are  tortuous,  and  have  often  two 
or  three  branches  in  the  deeper  parts  of  the  mucous  membrane.1 

In  the  cervix  the  mucous  membrane  is  thicker,  is  composed  of 

1  According  to  Dr.  Arthur  W.  Johnstone  of  Danville,  Ky.,  the  mucous  membrane 
is  an  adenoid  tissue,  like  that  of  the  tonsils,  the  thyroid  body,  the  spleen,  the  thy- 
mus,  the  lymphatic  glands,  and  the  lymph-tissues  in  the  wall  of  the  alimentary 
canal.  The  cells  originate  as  granules  in  the  fibres.  They  are  only  found  between 
the  age  of  puberty  and  the  climacteric  (Trans.  Brit.  Med.  <S'oc.,  June  23,  1886). 


ANATOMY. 


51 


FIG.  46. 


Section  of  the  Mucous  Membrane  of 
the  Uterus  parallel  to  the  surface, 
enlarged  150  times  (Henle) :  1,  2,  3, 
glands  (the  epithelium  has  fallen 
out  from  2) ;  4,  blood-vessel. 


fibrous  connective  tissue  without  adenoid  structure,  has  racemose 
glands,  and  is  separated  from  the  mus- 
cular layer  by  a  distinct  submucous 
layer  of  looser  connective  tissue.  The 
epithelium  is  columnar  and  ciliated  on 
the  free  surface  of  the  body,1  in  the 
utricular  glands,  and  on  the  edges  of 
the  branches  of  the  arbor  vitse.  In  the 
depressions  between  them  it  is  goblet- 
shaped,  without  cilia.  In  the  glands 
of  the  cervix  it  is  cuboidal,  without 
cilia. 

Shape  and  Position. — Opinions  as  to 
the  normal  shape  and  position  of  the 
womb  differ  so  much  that  it  has  almost 
become  a  confession  of  faith  to  say  any- 
thing about  it ;  but,  since  I  have  made 
gynecological  examinations  for  the  last 
twenty  years,  and  have  paid  special  at- 
tention for  the  last  ten  years  to  what 
can  be  seen  and  felt  in  regard  to  the 
anatomy  of  the  genitals,  I  think  I  may 
be  able  to  express  an  opinion  that  is  not 

altogether  without  foundation  in  facts,  as  are  so  many  descriptions  and 
drawings  given  of  these  parts.  We  have  five  sources  of  informa- 
tion— viz.  dissections  of  dead  bodies,  sections  of  frozen  bodies, 
bimanual  palpation  of  living  women,  laparotomies,  and  the  devel- 
opment of  the  fetus,  all  of  which  methods  have  some  advantages 
and  some  drawbacks ;  but  by  combining  them  all  I  think  we  get 
a  pretty  accurate  idea  of  the  true  relations.  After  death,  the 
body  lying  on  its  back,  the  whole  pelvic  floor,  especially  in  multip- 
arae,  is  apt  to  sink,  so  that  the  fundus  of  the  uterus  comes  to  lie 
considerably  deeper  than  in  the  living  woman,2  and  at  the  same  time 
it  falls  back  toward  the  sacrum.  Thus  all  descriptions  based  on 
autopsies  and  sections  of  frozen  bodies  become  unreliable.  On  the 

1  Having  stated  elsewhere  that  the  epithelium  of  the  body  was  columnar  without 
cilia — a  view  shared  by  such  an  authority  on  the  microscopical  anatomy  of  the 
female  genitals  as  De  Sinety  (Manuel  pratique  de  Gynecologic,  Paris,  1879,  p.  239) — • 
and  having  been  told  that  I  was  wrong,  I  addressed  Dr.  Johnstone  on  the  subject, 
who  recently  has  made  a  special  study  of  the  mucous  membrane  of  the  uterus.     He 
answered :  "  The  cause  of  the  difference  of  opinion  is  that  the  epithelium  on  the  free 
surface  of  the  corporeal  endometrium  is  shed  every  twenty-eight  days,  and  the  differ- 
ent observers  have  each  described  a  different  stage  of  its  regeneration.    I  have  seen  it  in 
all  conditions,  from  a  simple  round  cell  up  to  a  fully-developed  columnar  epithelium, 
and  in  a  few  instances  have  seen  what  looked  like  cilia.     But  before  they  become 
perfect  the  menstrual  flow  strips  off  the  epithelial  coat,  and  the  cycle  repeats  itself." 

2  According  to  Sappey,  it  should  lie  f  inch  to  1  inch  below  the  superior  strait. 


52 


DISEASES  OF  WOMEN. 


other  hand,  examinations  of  the  living  do  not  admit  of  the  same 
degree  of  accuracy  as  those  of  dead  bodies. 


FIG.  47. 


Fibre  of  Endometrium,  showing  different  degrees  of  corpuscular  development.    Enlarged 

3000  times    (Johnstone). 

The  canal  of  the  normal  uterus  is  straight  or  slightly  curved,  with 
the  concavity  turned  forward  (Fig.  49),  or  S-shaped.     The  presence 

FIG.  48. 


Epithelial  Cells  from  the  Uterus  of  a  Woman  sixty  years  old.  From  edge  of  a  plica  palmata : 
a,  ciliated  columnar  cell  (rare):  b,  plain  columnar  cell  (the  majority);  c,  large  goblet 
cells.  From  the  deepest  part  of  the  valley  between  two  plicae  palmatse:  d,  small  goblet 
cells.  From  inner  surface  of  body  :  e,  front  view;  /,  side  view,  columnar,  non-ciliated; 
nucleus  situated  nearer  lower  or  upper  end,  and  containing  one  or  two  nucleoli. 

of  an  angle  opening  anteriorly,  or  of  a  considerable  curvature  forward, 
is  an  abnormal  condition  called  anteflexion,  and  constitutes,  even  if 
it  does  not  give  rise  to  other  symptoms,  a  considerable  hindrance  to 
conception.  Any  kind  of  backward  curvature  constitutes  the  abnor- 
mal condition  called  retroflexion.  The  fundus  reaches  a  little  above 


ANATOMY. 


53 


the  brim  of  the  pelvis  (Fig.  50),  and  lies  a  little  nearer  to  the  right 
side  than  to  the  left.  When  the  rectum  and  bladder  are  empty,  the 
longitudinal  axis  of  the  womb  forms  a  right  or  obtuse  angle  with 
that  of  the  vagina.  A  full  bladder  will  tilt  the  womb  back  and  press 
it  up  against  the  sacrum,  and  a  full  rectum  presses  it  forward  to- 
ward the  symphysis.  The  small  intestine  is  regularly  found  in  the 

FIG.  49. 


Mesial  Section  of  the  Pelvis  of  a  Girl  seventeen  years  old,  half  natural  size  (Kolliker) :  ur, 
ureter  opening  into  bladder;  u,  vesical  opening  of  urethra;  d,  clitoris;  h,  hymen. 

upper  part  of  the  recto-uterine  excavation,  not  in  the  lowest,  narrow 
part  of  it,  Douglas's  pouch;  it  is  also  found  in  the  vesico-uterine 
excavation  if  the  bladder  contracts  in  such  a  way  as  to  form  a  Y 
(Fig.  34),  but  not  if  it  contracts  by  apposition  of  its  anterior  and 
posterior  wall,  in  which  case  the  womb  and  the  bladder  lie  close  up 
to  each  other  (Fig.  49). 

During  pregnancy  the  uterus  increases  enormously  in  size,  which 
is  especially  due  to  the  formation  of  new  muscular  cells  and  enormous 
increase  in  size  of  the  old  ones. 

After  the  menopause  the  organ  shrinks,  the  cervical  portion  forms 
a  small  protuberance  or  disappears  altogether,  and  the  mucous  mem- 
brane of  the  body  loses  nearly  all  its  cells  and  consists  of  common 
connective  tissue  (Fig.  51). 


DISEASES  OF  WOMEN. 
FIG.  50. 


Diagram  of  a  Supposed  Mesial  Section  of  the  Pelvis  of  a  living  woman  (Foster-Ranney) :  o, 
anal  canal ;  r,  rectum ;  v,  vagina ;  c,  clitoris ;  6,  bladder  when  collapsed ;  u,  uterus ;  d, 
valve  of  rectum  (Houston) ;  S,  symphysis  pubis ;  S ',  sacrum ;  C,  coccyx. 

FIG.  51. 


Endometrium  of  Woman  sixty  years  old  (Johnstoue).          , 

The  Ligaments  of  the  Uterus. — There  are  eight  ligaments  (Fig. 


ANATOMY. 


55 


52)  which  contribute  more  or  less  to  determine  the  position  and 
shape  of  the  uterus :  the  vesico-uterine  in  front,  the  sacro-uterine 
behind,  the  broad  and  the  round  at  the  sides. 


FIG.  52. 


Diagram  of  the  Ligaments  of  the  Uterus  (Hodge). 

The  vesico-uterine  ligaments  are  two  small  semilunar  folds,  one  on 
either  side  of  the  median  line  formed  by  the  peritoneum,  when  from 
the  bladder  it  passes  over  to  the  uterus,  on  the  level  of  the  internal  os. 

The  sacro-uterine  ligaments  are  much  larger  peritoneal  folds, 
extending  from  the  anterior  surface  of  the  second  sacral  vertebra  to 
the  uterus  on  a  level  with  the  os  internum.  Together  they  form  an 
oval  opening,  with  the  narrow  part  turned  toward  the  uterus.  Their 
concave  inner  edge  is  turned  inward  toward  the  rectum  (Fig.  53), 
and  forms  the  upper  border  of  Douglas's  pouch.  They  contain 
unstriped  muscle-fibres,  a  direct  continuation  of  those  of  the  womb, 
and  have  been  called  the  retractor  muscles  of  the  uterus  (Luschka). 
Besides,  they  contain  loose  and  fibrous  connective  tissue.  They  form, 
together  with  the  anterior  vaginal  wall,  an  elastic  beam  on  which  the 
uterus  is  suspended.1  They  prevent  the  uterus  from  being  pulled 
down  in  the  normal  condition  beyond  the  entrance  to  the  vagina. 

1  Frank  P.  Foster,  Trans.  Am.  Gyn.  Soc.,  1881,  voL  vi.  p.  434. 


56  DISEASES  OF   WOMEN. 

Working  together  with  the  round  ligaments,  their  shortening  produces 
anteflexion. 

The  broad  ligaments  are  two  quadrangular  folds  of  the  peritoneum, 
one  on  either  side,  situated  between  the  uterus  and  the  pelvic  wall, 
and  forming  a  partition  in  the  true  pelvis  between  an  anterior  and  a 
posterior  pouch.  The  inner  edge  is  attached  to  the  edge  of  the 
uterus,  the  outer  edge  to  the  wall  of  the  pelvis  in  a  line  extending 

FIG.  53. 


Superior  View  of  the  Pelvis  and  its  Organs  (Savage) :  B,  bladder ;  U,  uterus  (drawn  down  by 
loop  e) ;  F,  Fallopian  tubes ;  O,  ovaries ;  L,  round  ligaments ;  g,  ureter ;  a,  ovarian  vessels, 
often  prominent  under  their  peritoneal  covering. 

from  a  point  midway  between  the  sacro-iliac  articulation  and  the 
ilio-pectineal  eminence,  downward  and  backward,  between  the  great 
sacro-sciatic  notch  and  the  obturator  foramen,  to  the  level  of  the  spine 
of  the  ischium  (Fig.  54).  The  upper  edge  is  formed  by  the  Fallopian 
tube  inward  and  the  infundibulo-pelvic  ligament  outward.  The 
lower  edge  is  attached  to  the  mass  of  connective  tissue  lying  to  the 
side  of  the  cervix,  and  called  parametrium  or  parametric  connective 
tissue.  The  upper  edge  is  free ;  the  three  other  edges  are  continuous 
with  the  peritoneal  covering  of  the  uterus,  the  sides  and  the  floor  of 
the  pelvis.  It  is  composed  of  an  anterior  and  a  posterior  layer.  The 
anterior  layer  covers  the  round  ligament ;  the  posterior  layer  contains 
an  opening,  in  which  the  base  of  the  ovary  is  inserted.  Between 
these  two  layers  lie  loose  connective  tissue,  unstriped  muscular  fibres, 
blood-vessels,  lymphatics,  and  nerves.  The  muscular  fibres  are  a 
continuation  of  the  outer  layer  of  the  uterine  muscular  coat,  and  form 


ANATOMY.  57 


a  kind  of  flat  muscle  (platysma — Savage)  between  the  uterus,  the 
ovaries,  and  the  tubes,  from  which  a  bundle  goes  along  the  ovarian 
artery,  up  to  the  vertebral  column,  called  the  superior  round  ligament 
{Fig.  55,  LS).  This  whole  muscular  expansion  is  capable  of  producing 


FIG.  54. 


The  Right  Wall  of  the  Pelvis  (Polk):  A, ,  internal  iliac  artery;  B,  uterine  artery;  C,  ovarian 
artery;  D,  course  of  the  ureter,  projected  on  pelvic  wall;  E,  line  of  pelvic  attachment 
of  the  broad  ligament  of  the  uterus  in  a  nullipara  ;  F,  line  of  attachment  of  the  levator 
ani,  marking  the  level  of  the  base  of  the  broad  ligament. 

a  kind  of  erection  of  the  internal  genitals,  and  it  is  probably  also 
instrumental  in  adapting  the  fimbrise  of  the  tube  to  the  ovary  during 
ovulation  (Fig.  60). 

During  pregnancy  the  broad  ligaments  are  dragged  upward  and 
backward  by  the  uterus,  so  that  at  full  term  their  base  lies  on  a  level 
with  the  ilio-pectineal  line,  and  extends  from  the  ilio-pectiueal  emi- 
nence to  the  sacro-iliac  articulation.1  The  broad  ligaments  allow  the 
uterus  to  be  pushed  or  bent  forward  or  backward  to  any  extent ;  they 
allow  also  an  excursion  upward  and  downward  of  two  inches  in 
either  direction,  but  they  check  the  movement  from  side  to  side  some- 
what ;  and  when  the  utero-sacral  ligaments  are  cut  or  have  lost  their 

1  W.  M.  Polk,  "  Landmarks  in  the  Operation  of  Gastro-elytrotomy,"  N.  Y.  Mcd. 
Jour.,  May,  1882,  vol.  xxxv.  pp.  449-454 ;  as  well  as  his  "  Observations  upon  the 
Anatomy  of  the  Female  Pelvis,"  ibid.,  Dec.,  1882,  vol.  xxxvi.  pp.  561-569.  These 
papers,  based  upon  original  investigation  on  the  bodies  of  pregnant  women,  contain 
most  valuable  information  not  to  be  found  anywhere  else,  to  my  knowledge. 


58 


DISEASES  OF   WOMEN. 


elasticity,  the  broad  ligaments,  as  well  as  the  pelvic  connective  tissue, 
are  put  on  the  stretch  by  pulling  the  uterus  down. 

The  round  ligaments  (Fig.  55,  LI)  are  two  strings,  one  on  either  side, 
springing  from  the  anterior  surface  of  the  uterus  immediately  below 
and  in  front  of  the  Fallopian  tube,  and  going  in  a  curve  first  upward 


FIG.  55. 


-L8 


The  vessels  of  the  vagina  and  the  internal  genitals  in  their  relation  to  the  superficial  muscu- 
lar structures  (Rouget).  The  specimen  is  seen  from  behind.  Vascular  system:  VP, 
vaginal  plexus ;  PC,  cervical  plexus ;  PU,  uterine  plexus ;  HP,  helicine  arteries  of  uterine 
body ;  h,  helicine  arteries  of  hilum  of  ovary.  Muscular  system :  VP,  insertion  of  the 
muscle-bundles  of  the  vagina  on  the  pubes;  VS,  bundles  of  the  same  muscular  coat  com- 
ing from  the  region  of  the  sacro-iliac  articulation ;  US,  uterine  muscle-bundles  which 
accompany  the  preceding,  and  constitute  to  a  great  extent  the  posterior  layer  of  the  broad 
ligament;  UR,  recto-uterine  or  sacro-uterine  ligaments;  LI,  inguinal  or  pubic  round 
ligament,  spreading  over  the  whole  anterior  surface  of  the  uterus;  LO,  ovarian  ligament; 
.LS',  superior  or  lumbar  round  ligament,  which  accompanies  and  envelops  the  internal 
spermatic,  or  ovarian  vessels;  a,  muscular  bundles  coming  from  the  ovarian  ligament 
(LO),  spreading  and  interlacing  with  the  bundles,  b,  coining  from  the  superior  or  lumbar 
ligament  (LS).  in  the  interior  of  the  ovary,  and  beyond  in  the  ala  vespertilionis,  before 
they  insert  themselves  on  the  tube  and  the  fimbriae  ;  a',  bundles  starting  from  the  ovary, 
which,  together  with  others  corning  directly  from  the  superior  ligament,  form  the 
fimbria  ovarica. 

and  outward,  then  inward  and  forward,  outside  of  the  bladder,  to  the 
internal  inguinal  ring,  then  through  the  inguinal  canal,  following  its 
lowest  and  outermost  angle,  and  out  through  the  external  ring.  Here 
it  breaks  up  into  different  strands,  ending  in  the  mons  Veneris,  the 
symphysis  pubis,  and  the  upper  end  of  the  labium  majus.  Some 
strands  are  given  off  to  the  surrounding  parts  during  the  passage 
through  the  inguinal  canal. 

The  ligament  consists  of  fibrous  connective  tissue,  unstriped  mus- 


ANATOMY.  59 

cular  fibres  from  the  uterus,  and  striated  fibres  coming  from  the 
trausversalis  muscle  and  the  pubic  spine.  An  artery  from  the  deep 
epigastric  runs  through  its  centre  and  anastomoses  with  one  from  the 
uterus.  The  artery  is  accompanied  by  a  vein.  The  genital  branch  of 
the  genito-crural  nerve  lies  in  front  of  the  ligament  at  the  external 
ring.  Other  veins  and  nerves  join  it  from  below.  At  first  it  lies 
under  the  anterior  layer  of  the  broad  ligament.  When  it  leaves  the 
broad  ligament  it  has  a  peritoneal  covering  of  its  own,  which,  as  a  rule, 
stops  at  the  internal  ring  in  the  adult.  During  fetal  life  the  perito- 
neum forms  a  pouch  which  accompanies  it  through  the  inguinal  canal, 
and  is  called  the  canal  of  Nuck,  and  corresponds  to  the  processus 
vaginalis  in  the  male.  This  pouch  normally  grows  together,  forming 
a  fibrous  string,  but  abnormally  it  may  persist  and  give  rise  to  female 
hydrocele,  or  be  found  as  a  sheath  of  the  ligament  in  Alexander's 
operation.  (See  Retroflexion  of  Uterus.) 

During  pregnancy  the  round  ligament  becomes  finger-thick.  It  is 
only  found  in  women  and  the  higher  apes,  who  occasionally  take  the 
erect  position.  It  contracts  when  stimulated  by  electricity  like  other 
muscles.  Both  ligaments  being  contracted  at  the  same  time  they  tilt 
the  fundus  uteri  forward,  and  as  they  contract  simultaneously  with 
the  abdominal  muscles,  they  prevent  retroversion  from  being  produced 
by  coughing,  lifting,  straining  at  stool,  etc.1 

During  copulation  they  produce  probably  a  kind  of  suction,  and  by 
their  intimate  connection  with  the  muscular  platysma  of  the  broad 
ligament,  and  working  together  with  the  superior  round  ligament,  they 
cause  erection  of  the  inner  genital  organs.  During  labor  they  pull 
the  fundus  forward  and  downward,  and  thus  give  it  the  most  favor- 
able direction  in  relation  to  the  superior  strait. 

The  arteries  of  the  uterus  come  from  three  sources :  the  uterine 
artery  from  the  internal  iliac ;  the  ovarian  from  the  aorta ;  and  the 
insignificant  artery  of  the  round  ligament  from  the  epigastric.  The 
uterine  goes  behind  the  peritoneum  on  the  posterior  wall  of  the 
pelvis,  down  into  the  parametrium,  and  forms  a  loop  in  front  of  the 
ureter,  a  short  distance  ffom  the  anterior  lateral  fornix  of  the  vagina 
(Fig.  56).  (Compare  Fig.  54.)  Hence  it  goes  up  between  the  two 
layers  of  the  broad  ligament,  following  the  edge  of  the  uterus  to  the 
corner  of  the  same,  where  it  anastomoses  with  the  ovarian  artery.  It 
sends  numerous  branches  off  at  right  angles  to  the  uterus,  where  they 
anastomose  with  those  from  the  other  side  (Fig.  38).  At  the  level 
of  the  internal  os  such  anastomosing  branches  in  front  and  behind 
form  the  circular  artery.  The  trunk  has  a  very  tortuous  course,  and 
the  branches  are  wound  like  corkscrews,  helicine  arteries  (Fig.  55, 
H.  P.).  These  branches  have  so  small  a  lumen  and  so  thick  a  nms- 

1 J.  H.  Kellogg  of  Battle  Creek,  Mich.,  Trans.  Am.  Ass.  Obstet.  and  Oyn.,  1889,  vol. 
ii.  p.  266. 


60 


DISEASES  OF  WOMEN. 


cular  coat  that  in  many  cases  the  whole  uterus  can  be  cut  loose  from 
the  broad  ligament  without  using  ligatures  or  clamps  for  arresting 
hemorrhage. 

During  pregnancy  the  uterine  artery  stays  comparatively  small,  its 
calibre  equalling  that  of  the  ureter,  while  the  ovarian  is  much  thicker. 

The  uterine  veins  form  a  network  in  the  muscular  coat,  and  open 
into  a  conglomeration  of  veins  lying  at  the  edges  of  the  uterus. 
From  the  middle  of  this  plexus  the  two  uterine  veins  follow  the 
uterine  artery,  and  carry  the  blood  to  the  internal  iliac  vein.  At  its 
upper  end  this  plexus  anastomoses  with  the  branches  of  the  ovarian 

FIG.  56. 


t — c 


The  Uterine  Artery  in  its  Relation  to  the  Ureter :  a  photographic  reproduction  of  a  section  of 
the  pelvis,  extending  from  the  pectineal  eminence  above  to  the  lesser  sacro-sciatic  fora- 
men below  (Polk).  On  the  right  side  the  broad  ligament  has  been  removed  :  U,  uterus, 
right  side  freed  of  peritoneum  ;  0,  ovary ;  C,  base  of  bladder  showing  urethral  orifice, 
the  organ  having  been  cut  away  on  a  level  with  the  utero-vesical  peritoneal  fold  ;  the 
dotted  line  running  across  its  upper  edge  corresponds  to  the  utero-vaginal  junction; 
above  this,  at  F,  we  have  the  circular  artery  of  the  cervix;  A,  uterine  artery  ;  BB,  ureter, 
with  a  probe  passing  through  it ;  D,  ovarian  artery ;  E,  round  ligament,  held  up  to  show 
the  ovary  and  vessels  behind  it ;  R,  rectum. 

vein,  and  below  with  the  vaginal  and  vesical  plexuses.  The  ureter 
passes  right  through  it  (Fig.  57).  During  pregnancy  the  uterine 
veins  are  enormously  enlarged  and  form  the  so-called  sinuses,  large 
spaces  the  walls  of  which  only  consist  of  the  internal  coat  of  the 
veins,  and  are  intimately  bound  to  the  surrounding  muscular  tissue. 
The  Lymphatics. — The  uterus  is  exceedingly  rich  in  lymphatic 
spaces  and  vessels.  They  begin  in  the  mucous  membrane  as  open 
spaces  lined  with  endothelium,  and  separating  the  bundles  of  con- 
nective tissue.  In  the  muscular  layer  are  found  similar  spaces  and 
vessels,  and  they  all  communicate  with  a  superficial  network  of  ves- 
sels in  the  serous  membrane.  From  the  uterus  the  lymphatics  go 


ANATOMY. 


61 


through  the  broad  ligament.  Those  from  the  cervix  go  to  the  obtu- 
rator glands,  situated  at  the  inner  entrance  of  the  obturator  canal  and 
communicating  with  the  inguinal  glands.  Those  from  the  body  go 
to  the  internal  iliac  glands,  situated  between  the  external  and  internal 
iliac  artery,  and  which,  again,  send  vessels  to  the  sacral  glands  on  the 
anterior  surface  of  the  sacrum  and  to  the  lumbar  glands  in  front  of 
the  lumbar  vertebrae.  The  gland  of  the  isthmus  is  situated  in  the 
lower  inner  angle  of  the  broad  ligament. 

FIG.  57. 


The  Uterine  Veins  and  the  Ureter  (Luschka).  The  bladder  being  considerably  distended,  it 
was  cut  off  sufficiently  to  show  the  inner  surface  of  its  posterior  wall  where  it  is  in  con- 
tact with  the  uterus  and  the  vagina.  On  the  right  side  also  part  of  the  posterior  wall 
of  the  bladder  was  removed  in  order  to  show  the  course  of  the  ureter  on  the  anterior  wall 
of  the  vagina.  Where  the  uterus  and  the  vagina  are  concealed  by  the  bladder  their  con- 
tours are  marked  with  heavy  black  lines:  a.  anterior  surface  of  uterus,  showing  how  far 
it  is  covered  with  peritoneum  when  the  bladder  is  full ;  t>.  portion  of  supra  vaginal  part  of 
cervix  covered  by  the  bladder;  c,  vaginal  portion  of  uterus;  d,  vault  of  vasrina  :  r.  ante- 
rior wall  of  vagina;  ff,  cut  surface  of  bladder-wall ;  <j,  trigone;  h,  vesical  opening  of 
urethra ;  i,  i,  i,  venous  plexus  at  the  side  of  the  uterus  and  the  vagina ;  k,  right  ureter ;  I, 
left  ureter.  (Two-thirds  natural  size.) 

Tlie  Nerves. — Branches  from  the  second,  third,  and  fourth  sacral 
(spinal)  nerves  meet  with  others  from  the  hypogastric  plexus  (sympa- 
thetic) in  a  large  ganglion  on  either  side  of  the  cervix,  from  which 
cervical  ganglion  branches  go  to  the  uterus,  the  vagina,  and  the  blad- 


62  DISEASES  OF   WOMEN. 

der.  Those  of  the  uterus  end  in  the  nucleus  of  the  muscular  cells, 
and  in  ganglia  in  the  mucous  membrane. 

Function. — The  r6le  the  uterus  plays  as  a  copulative  organ  is  not 
quite  settled,  but  much  evidence  has  been  adduced  in  favor  of  the 
theory  that  it  exerts  a  suction  by  which  the  semen  is  drawn  into  its 
cavity.1  But  it  is  a  well-demonstrated  fact  that  conception  may  take 
place  independently  of  such  action. 

The  most  important  physiological  destination  of  the  womb  is  to 
furnish  a  place  of  attachment  for  the  ovum,  to  shelter  the  fetus  during 
its  development,  and  to  expel  the  child  during  parturition.2 

The  uterus  is  the  seat  of  the  chief  portion  of  the  menstrual  flow. 
At  the  menstrual  period  its  epithelium  is  thrown  off,  and  a  new  one 
is  formed  in  the  interval  between  two  menstruations. 

THE  FALLOPIAN  TUBES. 

The  Fallopian  tubes,  or  oviducts  (Fig.  58),  are  two  long,  slender, 
round  tubes  connected  with  the  upper  angles  of  the  uterus.  Their 

FIG.  58. 


Posterior  View  of  Left  Uterine  Appendages  (Henle):  1,  uterus;  2,  Fallopian  tube;  3,  fimbri- 
ated  extremity  and  opening  of  the  Fallopian  tube ;  4,  parovarium ;  5,  ovary ;  6,  broad 
ligament ;  7,  ovarian  ligament ;  8,  infundibulo-pelvic  ligament. 

length  varies  between  3  and  5  inches.  The  tube  starts  from  the 
highest  point  of  the  corner  of  the  womb,  above  the  round  ligament 
in  front  and  the  ovarian  ligament  behind.  From  thence  it  goes  first 
outward,  and  turns  then  backward,  lying  near  the  wall  of  the  pelvis, 

*  Joseph  E.  Beck,  Am.  Jour.  Obst.,  1874,  vol.  vii.  pp.  353-391. 

'  Several  cases  are  on  record  of  women  with  a  fracture  of  the  spine,  causing  com- 
plete paralysis  of  the  abdominal  muscles,  in  whom  the  child  was  expelled  by  the 
mere  contractions  of  the  womb. 


ANATOMY.  63 

above  and  in  front  of  the  ovary,  ami  finally  it  curves  round  the  free 
end  of  the  ovary,  the  abdominal  end  being  turned  against  the  ovary 
and  the  bottom  of  the  pelvis.  Sometimes  it  has  even  been  found 
surrounding  the  ovary  entirely,  with  the  abdominal  end  resting  on 
the  ovarian  ligament. 

It  may  be  divided  into  three  parts — the  isthmus,  the  ampulla,  and 
the  fimbria?.     The  isthmus  comprises  about  the  inner  third.     It  begins 

FIG.  59. 


Fallopian  Tube  laid  open  (from  Playfair,  source  unknown) :  ab,  uterine  portion  of  tube ;  cd, 
folds  of  mucous  membrane  ;  e,  tubo-ovarian  ligament,  or  fimbria  ovarica  ;  /,  ovary  ;  g, 
round  ligament. 

in  the  outermost  and  uppermost  corner  of  the  uterine  cavity  with  an 
opening  called  the  ostium  uterinum,  which  is  so  fine  that  it  barely 
admits  a  bristle.  It  goes  through  the  wall  of  the  uterus,  and  extends 
as  a  cord  about  £  inch  thick  outward.  The  ampulla  is  the  middle 
part,  which  is  twice  as  thick  or  more,  curved,  and  follows  a  serpentine 
course.  It  has  also  been  called  the  receptaculum  seminis,  because  it 
seems  to  be  particularly  destined  to  hold  and  preserve  the  spermato- 
zoids  until  they  come  in  contact  with  the  ovum.  Its  calibre  admits 
a  uterine  sound.  The  fimbrice  are  the  outermost  part.  They  sur- 
round the  outer  end  of  the  ampulla  like  a  collar  with  long  flaps. 
One  of  these,  the  fimbria  ovarica,  is  attached  to  the  free  end  of  the 
ovary,  and  forms  a  gutter.  In  the  middle  of  the  fimbria?  is  the  oatium 
abdominale,  which  again  is  a  very  fine  opening,  leading  into  the  peri- 
toneal cavity.  Often  a  pedunculated  hydatid  is  found  at  the  abdom- 
inal end.  This  was  originally  the  end  of  the  Mullerian  duct,  of 
which  the  tube  is  a  development. 

As  we  have  seen  in  the  chapter  on  Development,  the  tubes  have  a 
common  origin  with  the  uterus.  The  point  that  forms  the  limit 
between  the  two  is  the  insertion  of  the  round  ligament.  The  tube, 
like  the  uterus,  is  composed  of  three  layers — a  serous,  a  muscular, 
and  a  mucous — and  each  of  these  is  continuous  with  the  corresponding 


64  DISEASES  OF   WOMEN. 

layer  of  the  uterus.  The  serous  coat  is  formed  by  the  uppermost  part 
of  the  broad  ligament.  That  part  of  this  ligament  which  is  situated 
immediately  below  the  tube,  between  it  and  the  ovary,  is  called  the 
mesosalpinx,  or  the  ala  vespertilionis  (bat's  wing).  The  mesosalpinx 
is  continued  beyond  the  end  of  the  tube  as  the  so-called  infundibulo- 
pelvic  ligament,  which  goes  from  the  fimbrias  outward  and  backward 
to  the  iliac  fossa,  whence  it  carries  the  utero-ovariau  vessels  (internal 
spermatic)  to  the  tube  and  ovary. 

The  muscular  coat  consists  of  an  outer  longitudinal,  an  inner  circu- 
lar layer,  and  near  the  uterus  another  longitudinal  layer.1  It  contains 
most  of  the  blood-vessels. 

The  mucous  membrane  forms  large  and  small  longitudinal  folds 
(Fig.  59).  It  covers  the  inner  side  of  the  fimbrise,  while  the  outer 
side  is  covered  with  peritoneum.  It  has  a  single  layer  of  ciliated 
columnar  epithelium,  the  cilia  of  which  move  in  such  a  way  as  to 
push  the  ovum  in  the  direction  of  the  uterus.  With  increasing  age 
the  ciliated  epithelium  is,  however,  partially  replaced  by  non-ciliated 
columnar  and  flat  epithelium.  The  mucous  membrane  has  no  glands.2 
The  muscular  expansion  from  the  outer  layer  of  the  uterus  extends 
to  the  tube,  and  seems  to  be  able  to  cause  an  erection  of  it. 

The  uterine  end  moves  with  the  uterus;  the  remainder  is  still 
more  freely  movable,  since  the  tube  is  much  longer  than  the  straight 
line  between  its  two  ends,  and  its  movements  are  only  checked  by  the 
thin,  loose,  elastic  mesosalpinx,  the  fimbria  ovarica,  by  which  it  is 
connected  with  a  movable  ovary,  and  the  infundibulo-pelvic  liga- 
ment. 

The  arteries  of  the  Fallopian  tubes  come  from  the  ovarian  artery 
(Fig.  38). 

The  veins  go  to  the  pampiniform  plexus  in  the  broad  ligament. 

The  lymphatics  unite  with  those  of  the  ovary  and  go  to  the  lumbar 
glands. 

The  nerves  come  from  the  inferior  hypogastric  plexus  of  the  sym- 
pathetic. 

Function. — The  Fallopian  tubes  are  the  canals  through  which  the 
ova  pass  from  the  ovaries  to  the  uterus,  and  in  which  probably,  in 
most  cases,  impregnation  takes  place  by  the  union  of  an  ovum  and 
one  or  more  spermatozoids.  It  seems  that  during  menstruation  the 
fimbriae  are  spread  out  and  applied  with  their  mucous  side  to  the 
ovary,  so  as  to  catch  the  ovum  when  it  leaves  the  Graafian  follicle 
(Fig.  60).  The  surface  of  the  ovary  being  four  or  five  times  larger 
than  that  of  the  fimbriae,  it  seems,  however,  impossible  that  these 
should  always  cover  a  bursting  follicle.  Many  ova  doubtless  fall  into 
the  peritoneal  cavity.  The  accompanying  blood,  if  in  small  quantity, 

1  J.  Whitridge  Williams,  Am.  Jour.  Med.  Sci.,  Oct.,  1891,  vol.  cii.  p.  378. 

2  Otto  Cohen,  Med.  Monatsschr,  New  York,  Sept.,  1890,  vol.  ii.  p.  413. 


ANATOMY.  65 


is  absorbed.     If  copious,  it  forms  periuterine  hematocele.     The  ova 
perish  or  give  rise  to  abdominal  pregnancy.     Some  may  also  be  sec- 


FIG.  60. 


Tube  and  Ovary  of  a  Woman  who  died  during  menstruation,  natural  size  (Farre) :  I,  broad 
ligament ;  o,  ovary ;  rr,  old  corpora  lutea ;  /,  istbmus  of  tube ;  i,  flmbriated  end  spread 
over  ovary. 

ondarily  attracted  to  the  Fallopian  tubes  by  the  current  produced  by 
the  movement  of  their  cilia. 


THE  OVARIES. 

The  ovaries  (Fig.  61)  are  two  oval  bodies  situated  in  the  true 
pelvis,  to  the  sides  of  the  uterus,  below,  behind,  and  to  the  inner  side 
of  the  Fallopian  tubes.  They  are  about  1J  inches  long,  1  inch  wide, 
and  ^  inch  thick.  They  are,  as  it  were,  inserted  in  a  hole  in  the 
posterior  layer  of  the  broad  ligament,  as  a  diamond  is  fastened  to  a 
ring.  They  are  covered  with  a  single  layer  of  hexagonal  columnar 
epithelial  cells,1  such  as  we  find  on  mucous  membranes,  and  entirely 
different  from  the  large,  flat  endothelial  cells  covering  the  peritoneum. 
Their  long  axis  is  placed  diagonally  in  the  pelvis.  They  have  an 
inner  anterior  end,  an  outer  posterior  end,  an  anterior  outer  edge,  a 
posterior  inner  edge,  an  upper  anterior  outer  surface,  and  a  lower 
posterior  inner  surface.2  The  inner  end  is  fastened  to  the  corner  of 
the  uterus,  behind  and  below  the  tube,  by  means  of  the  ligament  of 

1  As  some  authors  deny  the  fact,  first  pointed  out  by  Waldeyer,  that  the  ovary  is 
not  covered  with  peritoneum,  I  wish  to  state  that  I  have  satisfied  myself  by  numer- 
ous examinations  of  ovaries  of  women  of  the  correctness  of  tine  above. 

2  The  reader  will  understand  this  much  more  readily  if  he  takes  an  oblong  box 
and  gives  the  surfaces,  ends,  and  edges  the  above  indicated  directions. 

5 


66 


DISEASES  OF  WOMEN. 


the  ovary,  a  round  string,  about  an  inch  long,  running  at  the  upper 
edge  of  the  broad  ligament,  between  its  two  layers,  and  composed  of 
connective  tissue  and  unstriped  muscle-fibres,  which  are  a  continua- 
tion of  the  outer  layer  of  the  uterine  muscular  tissue.  This  inner 


FIG.  61. 


LO 


Ovary  and  Tube  of  a  Nineteen-year-old  Girl  (Waldeyer) :  U,  uterus;  T,  tube;  LO,  ovarian 
ligament  (of  unusual  length) ;  o,  ovary ;  x,  limit  of  peritoneum.  (The  inner  end  of  the 
ovary  is  too  high.) 

end  of  the  ovary  is  tapering  and  thinner  than  the  outer.  The  outer 
end  is  broader,  fastened  above  to  the  fimbria  ovarica  and  below  to 
the  infundibulo-pelvic  ligament  (Fig.  61).  The  anterior  edge  is 
nearly  flat,  and  bound  to  the  posterior  layer  of  the  broad  ligament. 
The  place  where  the  vessels  and  nerves  enter  is  called  the  hilum.  A 
white  line  marks  the  abrupt  transition  from  the  peritoneum  to  the 
ovarian  epithelium,  and  this  is  situated  on  a  higher  level  on  the 
anterior  surface  than  on  the  posterior.  The  anterior  surface  is  less 
convex  than  the  posterior.  The  posterior  edge  is  strongly  convex 
and  free.1  The  ovaries  lie  above  the  retro-ovarian  shelves  (which 
will  be  described  later  in  speaking  of  the  pelvic  peritoneum),  are  sur- 
rounded with  coils  of  the  small  intestine,  and  lie  near  the  rectum. 
By  introducing  one  or  two  fingers  into  the  vagina  as  high  up  as  pos- 
sible to  the  sides  of  and  behind  the  uterus,  and  depressing  the  abdom- 
inal wall  in  the  region  of  the  iliac  fossa,  the  ovaries  can  sometimes  be 
felt. 

In  a  young  girl  the  surface  of  the  ovary  (Fig.  61)  is  even,  smooth, 
velvety,  of  pearl-gray  color. 

Later,  each  ovulation  leaving  a  little  puckered  cicatrix,  the  surface 

1  By  the  data  given  above  it  is  easy  to  distinguish  the  left  from  the  right  ovary, 
but  the  only  way  of  obtaining  a  correct  idea  of  the  ovary  is  by  remembering  that  it 
has  a  uterine  end  and  a  tubal  end,  an  attached  border  and  a  free  border,  a  smaller 
and  a  larger  surface,  for  the  organ  is  so  movable  that  it  is  found  in  the  most  different 
positions,  so  that  expressions  like  upper  and  lower,  inner  and  outer,  are  taken  in 
the  opposite  sense  by  different  authors. 


ANATOMY. 


67 


becomes  harder  and  shows  irregular  depressions  (Fig.  62),  and  in  old 

age  it  becomes  nearly  cartilaginous  and  loses  partly  its  epithelium. 

As  to  its   composition,  the   ovary  may  even    macroscopically  be 

divided  into  an  outer  part,  called  the  parencJiymatous  zone,  or  corti- 


FIG.  62. 


LO'' 


Ovary  and  Tube  of  Girl  twenty-four  years  old  (Waldeyer) ;  U,  uterus;  T,  tube  ;  LO,  ovarian 
ligament ;  o,  ovary  ;  x,  limit  of  peritoneum ;  6,  cicatrice  after  ruptured  Graaflan  follicle. 

cat  substance,  and  an  inner,  called  the  vascular  zone,  or  medullary 
substance. 

The  microscopical  examination  shows  a  greater  number  of  layers. 
Under  the  columnar  epithelium  is  found  a  narrow,  somewhat  harder 
layer  called  the  albuginea  (Figs.  63  and  64).  It  is  intimately  con- 
nected with  the  subjacent  parenchyma,  from  which  it  cannot  be  dis- 
sected off.  Under  the  microscope  three  layers  may  be  distinguished 
in  it.  It  is  composed  of  fibrous  connective  tissue  with  interspersed 
unstriped  muscle-fibres.  Under  the  albuginea  is  found  a  zone  dis- 
tinguished by  the  presence  of  small  follicles  containing  an  ovum,  the 
so-called  ovisacs,  or  young  Graafian  follicles.  Inside  of  this  zone  is 
found  another  with  much  larger  Graafian  follicles.  The  tissue  in 
which  these  follicles  are  imbedded  consists  chiefly  of  unstriped  mus- 
cle-fibres and  connective  tissue,  which  are  arranged  in  circles  around 
each  follicle.  The  centre  is  formed  by  the  so-called  meduttary  sub- 
stance, or  vascular  zone.  Here  the  connective  tissue  is  much  looser 
than  in  the  parenchymatous  zone,  but  it  is  full  of  unstriped  nmscle- 
fibres,  as  well  as  the  parenchymatous  zone.  The  largest  vessels  are 
found  most  centrally  and  nearest  the  hilum.  Nearer  the  surface  and 
the  free  end  they  are  smaller.  A  diagram  (Fig.  65)  may  help  to 
realize  how  these  zones  are  distributed  on  a  transverse  section  of  a 
human  ovary.  The  whole  section  appears  pear-shaped,  the  zones 


68 


DISEASES  OF  WOMEN. 


being  narrower  near  the  hilura  and  increasing  in  width  toward  the 
free  border.1 

The  small  follicles,  measuring  from  0.02  to  0.08  millimeter  in 
diameter,  are  the  same  we  have  described  in  the  history  of  the  devel- 
opment (p.  26),  but  of  the  enormous  number  comparatively  few  are 
left.  The  large  follicles  constitute  more  properly  what  is  called 
Graafian  follicles,  and  can  be  seen  with  the  naked  eye  as  vesicles  of 
the  size  of  French  peas. 

FIG.  63. 


Section  of  the  Ovary  of  a  Cat,  enlarged  six  times  (Schron) :  1,  outer  covering  and  free  border 
of  the  ovary  (epithelium  and  albuginea) ;  1',  attached  border;  2,  vascular  zone,  or  medul- 
lary substance  ;  3,  parenchymatous  zone,  or  cortical  substance ;  4,  blood-vessels :  5,  Graafian 
follicles  in  their  earliest  stages,  lying  near  the  surface ;  6,  7,  8,  more  advanced  follicles, 
imbedded  more  deeply  in  the  stroma ;  9,  an  almost  mature  follicle,  containing  the  ovum 
in  its  deepest  part ;  9',  a  follicle  from  which  the  ovum  has  accidentally  escaped ;  10,  corpus 
luteum. 

There  are  from  six  to  twenty  of  these  large  follicles  in  an  ovary. 
The  ovisacs  do  not  migrate.  It  is  simply  by  their  increased  size  that 
the  larger  follicles  seem  to  form  a  zone  inside  of  the  small  ones.  In 
growing  they  push  the  surrounding  tissue  aside  and  extend  deep  into 
the  interior  of  the  ovary,  and  at  the  same  time  closer  to  its  sur- 
face, until  finally  all  tissue  between  the  follicle  and  the  surface  is 
absorbed  and  the  follicle  can  burst  there. 

The  wall  of  the  Graafian  follicle  (Fig.  66)  consists  of  two  layers,  an 
outer,  denser,  called  tunica  fibrosa,  composed  of  fibres  of  connective 
tissue,  and  an  inner,  more  delicate,  softer,  called  tunica  propria,  and 
containing  many  cells  and  a  fine  network  of  capillary  vessels.  Al- 
though there  is,  microscopically,  no  line  of  demarkation  between  the 
follicles  and  the  surrounding  tissue,  they  are  easily  pulled  out.  Inside 
of  the  tunica  propria  are  found  several  layers  of  epithelial  cells,  together 

1  When  I  state  above  that  the  ovary  is  pervaded  by  unstriped  muscle-fibres,  it  is 
because  I  have  good  authority  for  it  (Sappey  and  others),  and  because  I  have  myself 
occasionally  seen  them  form  bundles  exactly  like  those  in  other  organs  where  their 
identity  is  recognized  by  everybody.  But  some  authors  do  not  admit  that  the  cells 
we  see  forming  the  bulk  of  the  tissue  between  the  follicles  are  of  muscular  nature. 


ANATOMY. 


69 


called  the  membrana  gmnufosa,  and  between  the  epithelial  cells  and 
the  tunica  propria  there  is  a  structureless  membrane.     On  one  side 


FIG.  64. 


Part  of  the  Same  Section  as  represented  in  Fig.  63,  more  highly  enlarged  (Schron) :  1.  the  epi- 
thelium and  albuginea;  2,  fibrous  stroma;  3,  3',  less  fibrous,  more  superficial  stroma;  4, 
blood-vessels ;  5,  small  Graafian  follicles  near  the  surface ;  6,  one  or  two  more  deeply 
placed;  7,  one  further  developed,  enclosed  by  a  prolongation  of  the  fibrous  stroma;  8,  a 
follicle  still  further  advanced;  8',  another,  which  is  irregularly  compressed ;  9,  part  of 
the  largest  follicle :  a,  membrana  granulosa ;  b,  discus  proligeriis ;  c,  ovum ;  d,  germinal 
vesicle;  e,  germinal  spot. 

these  epithelial  cells  form  a  mass  protruding  into  the  cavity  of  the 

FIG.  65. 


Zone  of  fine 
vessels 

Loose  connect- 
ive tissue  with 
large  vessels. 


j  layers 

Zone  of  small 
follicles 

Zone  of  large 
follicles 


Columnar 
epithelium 


ffilum 

Diagram  of  Zones  in  Human  Ovary. 


follicle,  and  called  discus  proligerus  (Fig.  64,  6).     The  outermost 


70 


DISEASES  OF  WOMEN. 


layer  of  epithelial  cells  of  the  Graafian  follicle  has  a  regular  columnar 
shape ;  the  inner  ones  are  more  irregular  and  breaking  down,  except 
those  immediately  surrounding  the  ovum,  which  again  form  a  regular 
single  layer  of  columnar  cells.  The  space  between  this  epithelium 
and  the  discus  proligerus  is  filled  with  a  clear  serous  fluid  called 
liquor  folliculi,  which  contains  a  few  cells,  albumin,  and  paralbumin. 
It  is  formed  by  liquefaction  of  the  cells  of  the  membrana  granulosa. 

FIG.  66. 


Graafian  Follicle  of  Adult  Woman,  40 : 1  (De  Sinety) :  a,  external  layer,  or  tunica  fibrosa ;  b, 
internal  layer,  or  tunica  propria ;  c,  blood-vessels ;  d,  membrana  granulosa ;  e,  discus 
proligerus ;  I,  liquor  folliculi  (coagulated) ;  o,  ovum. 

In  the  discus  proligerus  is  imbedded  the  ovum  (Fig.  67).  The 
human  ovum  is  0.2-0.3  millimeters  in  diameter,  or  just  about  visible 
with  the  naked  eye.  The  surrounding  cells  form  a  regular  epithelial 
layer  of  short  columnar  cells  all  around  it.  Inside  of  that  is  found 
a  fine  membrane  with  radiating  striae,  the  zona  pellucida,  or  vitelline 
membrane.1  The  interior  is  filled  with  a  semifluid  mass  called  the 
viteUus.  This  is  composed  of  larger  clear  bodies  and  minute  dark 
ones,  and  one  much  larger  vesicle  called  the  germinal  vesicle.  The 
latter  contains  a  little  round  body  called  the  germinal  spot.  In  the 
interior  of  the  latter  are  found  a  few  small  dark  granules,  and  some- 
times similar  bodies  are  found  in  the  germinal  vesicle  outside  of  the 
germinal  spot. 

After  the  climacteric  age  the  follicles  and  ova  disappear,  the  whole 
organ  shrinks,  and  its  surface  is  very  uneven. 

Corpivs  Lideum  of  Menstruation. — The  Graafian  follicle  undergoes 
certain  changes.  As  a  rule,  one  attains  during  the  intermenstrual 

1  The  vitelline  membrane  is  something  entirely  different  from  the  yolk-sac, 
although  one  name  might  seem  to  be  a  translation  of  the  other. 


ANATOMY.  71 

period  the  size  of  a  liazelnut  (J  inch  or  more  in  diameter),  the  tissue 
between  it  and  the  surface  becomes  thinner  and  thinner,  until,  finally, 
it  bursts  and  lets  the  ovum  escape.  The  follicle  is  then  filled  with 
blood,  which  coagulates,  forming  a  cherry-colored  clot  (Fig.  69).  A 
few  days  later  the  wall  begins  to  be  enlarged  and  thickened,  and  this 
enlargement  within  a  confined  space  causes  it  to  become  folded  upon 
itself  in  short  zigzag  reduplications,  mainly  at  the  deeper  part  of  the 

FIG.  67. 


Mature  Ovum  of  Rabbit,  Hartnack  f  (Waldeyer) :  a,  cells  from  the  discus  proligerus  (epi- 
thelium of  ovum);  6,  zona  pellucida;  c,  vitellus;  d,  germinal  vesicle;  e,  germinal  spot; 
/,  large  globules  with  dull  lustre  in  the  germinal  vesicle. 

follicle  (Fig.  70).  These  folds  grow  into  the  clot,  and  finally  replace 
it.  In  this  way  is  formed,  during  the  intermenstrual  period,  a  corpus 
luteum,  occupying  the  substance  of  the  ovary  immediately  beneath 
the  superficial  cicatrix  which  marks  the  site  of  the  ruptured  follicle 
(Fig.  71).  Subsequently  the  whole  structure  diminishes  in  size,  and 
becomes  more  and  more  intimately  connected  with  the  surrounding 
tissue,  so  that  it  can  no  longer  be  peeled  out  in  toto.  In  a  regularly 
menstruating  woman  it  seldom  happens  that  we  do  not  find  three  or 
more  corpora  lutea  in  dhTerent  stages  of  growth  or  retrogression. 
The  volume  of  the  menstrual  corpora  lutea  varies  between  about  one- 
half  and  one  cubic  centimeter.  By  the  eleventh  week  after  menstrua- 
tion it  is  less  than  one-twentieth  of  a  cubic  centimeter. 

Corpus  Luteum  of  Pregnancy. — If  pregnancy  takes  place,  no  new 
corpora  lutea  are  formed,  but  the  one  corresponding  to  the  last  men- 
struation becomes  larger  and  stays  longer.  After  the  first  mouth  it 
continues  to  increase  in  size,  or,  at  least,  does  not  diminish,  and  its 
convoluted  wall  assumes  the  strong  yellow  hue  which  has  given  rise 


72 


DISEASES  OF   WOMEN. 


to  its  name.  At  the  same  time  the  central  clot  becomes  fully  decolor- 
ized, growing  denser  and  firmer  in  proportion  as  it  diminishes  in 
bulk,  until  a  firm  white  fibrinous  clot  is  found  in  the  centre  of  the 
yellow  ring  (Fig.  72).  Sometimes  this  clot  has  itself  a  central  cavity 
tilled  with  a  serous  fluid.  Beyond  a  certain  period  of  pregnancy,  the 
date  of  which  is  not  precisely  known,  the  corpus  luteum  diminishes 
in  size,  and  loses  the  freshness  of  its  yellow  hue.  At  the  end  of 
pregnancy  it  is  reduced  to  about  one-half  of  a  cubic  centimeter.1 

1  According  to  Dr.  Mary  A.  Dixon  Jones,  working  under  the  auspices  of  Dr. 
Charles  Heitzmann,  the  process  taking  place  in  the  ovary,  in  connection  with  men- 
Btruation,  is  a  different  one.  They  claim  that  the  wall  of  the  follicle  bursts,  not  only 
on  the  surface  of  the  ovary,  but  in  many  places,  and  that  an  extravasation  of  blood 
follows  into  the  surrounding  tissue,  where  it  sets  up  a  mild  degree  of  inflammation. 
The  fibrous  connective  tissue,  as  well  as  the  unstriped  muscle-fibres,  in  the  vicinity 
of  the  follicle  are  reduced  to  a  protoplasmic  condition,  and  immediately  outside  of 
the  follicle  the  tissue  is  infiltrated  with  granular  inflammatory  corpuscles  ( or  medul- 
lary elements)  which  enter  the  follicular  cavity  (Fig.  68),  and  gradually  are 

FIG.  68. 


Menstrual  Follicle  ten  to  twelve  days  after  rupture  X  600  (M.  Dixon-Jones) :  E,  extravasated 
blood ;  S,  structureless  membrane ;  C,  capillary  blood-vessels ;  F,  fibrous  connective  tissue. 

transformed  there  to  a  myxomatous  tissue,  destitute,  as  a  rule,  of  blood-vessels,  but 
showing  now  and  then  cavities,  probably  caused  by  a  liquefaction  of  the  myxomatous 
substance  (Fig.  74).  With  advancing  age  the  myxomatous  tissue  becomes  less 
and  less,  until  nothing  is  left  of  the  original  follicular  wall  but  the  so-called  struc- 
tureless membrane  distinctly  convoluted  and  imbedded  in  ovarian  tissue,  (New  York 
Med  Jour.,  May  10  and  17,  1890). 
According  to  Dr.  Jones,  the  so-called  corpus  luteum  of  pregnancy  is  a  pathological 


FH;.  7.°,. 

FIG.  69.— Ovary  of  Woman  two  days  after  Menstruation  (Dalton),  showing  earliest  stage  o 

a  ruptured  and  bloody  Graarian  follicle  into  a  corpus  luteum. 
Fiu.  70  —Ovary  of  Woman  twenty  days  after  Menstruation  (Dalton).    Besides  large  fresh 

seen  two  smaller  old  ones,  and  Graatian  follicles  of  different  size. 
Fiu.  71. -Ovary  of  Woman  nine  days  after  Menstruation  (Dalton).    The  dark  spot  is  the 

rounding  yellow  circle  is  the  corpus  luteum  shining  through  the  transparent  tissue. 
Fio.  72.— Ovary  of  Woman  at  Term  of  Pregnancy  (Dalton),  showing  corpus  luteum  with  linu 
FIG.  78.— False  Corpus  Luteum  (Dalton). 


ANATOMY. 


73 


False  Corpora  Lutea. — Sometimes  Graafian   follicles   degenerate. 
The  wall  becomes  thick,  opaque,  whitish,  and  assumes  a  slightly  car- 


Normal  Menstrual  Body  X  100  (M.  Dixon-Jones) :  CC,  cortex  of  ovary  ;  S,  so-called  structure- 
less membrane,  broken;  3f,  myxomatous  tissue  filling  the  previous  follicle;  0,  old  men- 
strual body,  remnants  of  structureless  membrane ;  VV,  veins. 

tilaginous  consistency.  The  fluid  in  the  interior  disappears,  and  the 
opposite  surfaces  come  in  contact  with  each  other.  The  ovum  dis- 

formation  which  she  calls  gyroma,  and  which  we  shall  describe  in  speaking  of 
oophoritis.  It  may  be  found  in  women  who  have  never  been  pregnant,  and  be 
absent  in  those  who  have  borne  children  (New  York  Med.  Jour.,  May  10  and  17, 
1890;  Times  and  Register,  Philad.,  Apr.  30,  1892).  In  my  opinion,  the  gyromas, 
the  existence  of  which  I  am  familiar  with  myself,  are  what  Patenko  has  described 
under  the  name  corpora  fibrosa  (Virchow's  Archiv,  1881,  vol.  Ixxxiv.  pp.  193-207) 
—an  abnormal  formation  which  differs  from  the  normal  corpus  luteum  of  preg- 
nancy. 


74  DISEASES  OF  WOMEN. 

appears  also.  These  follicles  lie  in  the  deeper  parts  of  the  ovary,  and 
do  not  communicate  with  the  surface  (Fig.  73,  colored  plate,  p.  72). 
They  may  be  called  false  corpora  lutea.1  When  the  corpus  luteum 
has  lost  its  yellow  color  and  most  of  its  vessels,  and  is  chiefly  com- 
posed of  connective  tissue,  it  is  called  corpus  albicans.  If  such  a 
body  contains  dark  pigment,  it  is  not  white,  but  dark  brown  or  black, 
and  is  called  corpus  nigrum  or  corpus  nigricans.2 

Quite  frequently  large  or  small  extravasations  of  blood  are  found 
in  the  tissue  of  the  ovary.3 

The  ovary  has  a  rich  supply  of  blood-  and  lymph-vessels,  which 
enter  at  the  hilum.  The  arteries  (Fig.  38,  colored  plate,  p.  44)  come 
from  the  ovarian  artery,  follow  a  spiral  course,  and  end  in  a  fine  cap- 
illary network  in  the  tunica  propria  of  the  follicles.  They  have  very 
thick  walls  and  a  small  calibre.  The  veins  follow  the  arteries,  and  go 
to  the  pampiniform  plexus  in  the  broad  ligament.  From  that  the 
blood  is  carried  through  the  ovarian  veins.  The  right  opens  into  the 
inferior  vena  cava,  and  has  a  valve ;  the  left  opens  into  the  renal  vein 
at  right  angles,  and  has  no  valve.  The  latter  circumstance  is  per- 
haps the  explanation  of  the  much  greater  frequency  of  pain  in  the 
left  side  of  the  pelvis  than  the  right  in  gynecological  patients.  The 
ovarian  veins  anastomose  with  the  uterine  (Fig.  57,  p.  61).  They 
are  imbedded  in  the  tissue  in  the  same  manner  as  those  of  the  uterus. 
The  lymphatics  begin  around  the  follicles,  follow  the  veins,  and  go  to 
the  lumbar  glands.  The  nerves  come  from  the  inferior  hypogastrio 
plexus  (Fig.  31,  colored  plate,  p.  39). 

Function. — The  ovary  produces  and  expels  the  ova  by  which  the 
species  is  propagated.  The  expulsion  is  probably  brought  about  by 
contraction  of  the  unstriped  muscle-fibres  which  form  so  large  a 
portion  of  the  organ,  combined  with  congestion. 

THE  PAROVARIUM. 

The  parovarium  (Fig.  78)  is  a  remnant  of  the  Wolffian  body  (see 
p.  22).  It  is  situated  in  the  connective  tissue  between  the  two  layers 

1  The  term  "  false  corpus  luteum "  is  often,  but  less  properly,  used  in  the  sense 
of  corpus  luteum  of  menstruation. 

2  John  C.  Dalton,  "  Report  on  the  Corpus  Luteum,"  Am.  Gyn.  Trans.,  1877,  vol.  ii. 
pp.  111-160. 

3  In  1879-80,  while  investigating  abdominal  fluids,  I  made  numerous  sections  of 
apparently  normal  human  ovaries.     In  so  doing  I  got  the  impression  that  there  are 
many  processes  going  on  in  the  ovaries  which  are  not  yet  described.     Other  work 
has  prevented  me  from  following  this  track,  but  it  may  be  permissible  here  to  point 
out  the  large  number  of  yellow  masses  we  find  in  seemingly  normal  ovaries  of 
women.     Fig.  75  is  drawn  in  natural  size  from  the  ovary  of  a  woman  thirty-six 
years  old,  cut  open  lengthwise.     Under  the  albuginea  was  found  a  red  zone  with 
three  Graafian  follicles,  and  the  whole  interior  was  taken  up  by  yellow  tissue  indis- 
tinctly divided  into  several  parta 

Fig.  76  is  likewi.«  drawn  from  nature,  in  the  exact  size.     It  represents  the  ovary 


ANATOMY.  t          75 

of  the  broad  ligaments,  between  the  outer  end  of  the  ovary  and  the 

ampulla  of  the  Fallopian  tube.     It  can  be  seen 

by  holding  the  broad   ligament  up  against  the  FIG.  75. 

light.     It  is  a  small,  flat,  triangular  organ,  the 

apex  of  which  touches  the  attached  edge  of  the 

ovary.     It  is  composed  of  from  six  to  thirty  spiral 

tubules.     At  the  base  these  tubules  open  into  one 

transverse  tube,  which  may  be  followed  as  a  solid 

cord  in  the  direction  of  the  uterus.     This  tube     f"" 

and  cord  correspond  to  Gartner's  canal  in  certain 

animals  (see  p.  20),  and  are  a  remnant  of  the    ovary  of  woman  thirty- 

Wolffian  duct.     The  tubules  have  a  wall  com-       si^e^aib1uVm1faU;r&! 

posed  of  con uecti ve  tissue,  unstriped  m uscle-fi bres,       fed  zone ;  c,  d,  e,  Graaf- 

,         ...        ,        .  •  i     !•  *        i  ian  follicles   situated 

and  a  ciliated  columnar  epithelium.     At  the  outer  in  the  red  zone,  which 

side  there  are  some  tubules  which  do  not  reach  the  the  remainders  taken 

ovary,  and  one  of  them,  the  end  of  the  transverse  llfdisSnctf^^divfded 

tube,  terminates  often  in  a  small  cvst  similar  to  int<?    several    parts, 

,,        ',      ,    ..j      ,.    T,r  •   /        orn       *  A  A    -LU       •  probably   corpora  lu- 

the  fiyaatid  of  Morgagm  (p.  30).     At  the  inner       tea  of  menstruation 

•j  i_"L    i  !•  IL  i.  i         j.u    •  in    retrograde    meta- 

side  there  are  some  tubules  which  have  lost  their       morphosfs. 
lumen  and  become  fine  cords. 

The  parovarium  has  no  function,  but  is  liable  to  become  the  seat 
of  cystic  degeneration. 

THE  URINARY  ORGANS  AND  THE  RECTUM. 

The  urethra,  the  bladder,  the  ureters,  and  the  rectum  are  so  closely 
connected  with  the  genitals,  and  the  gynecologist  is  so  often  called 
upon  to  treat  diseases  in  these  parts,  that  a  brief  re'sume'  of  their 
anatomy  would  seem  indispensable. 

THE  URETHRA. 

The  urethra  is  a  canal  leading  from  the  bladder  to  the  vulva.  It 
is  from  1  to  1J  inches  long  and  ^  inch  in  diameter,  but  very  dis- 
tensible. It  is  usually  said  to  be  straight  or  slightly  S-shaped, 
but  these  descriptions  are  based  upon  post-mortem  examinations. 
The  fact  that  a  catheter  is  best  introduced  by  performing  a  curve 
round  the  lower  end  of  the  symphysis  pubis,  leads  me  to  believe  that 

of  a  woman  forty -seven  years  old.  It  shows  a  corpus  luteum,  a  large  yellow  mass, 
•  and  thirteen  distinct  small  yellow  masses.  Examined  under  the  microscope,  these 
masses  prove  to  be  follicles  with  irregular  lumps  of  yellow  pigment  interspersed  in 
the  thin  tissue  between  the  follicles,  and  sometimes  in  the  follicles  themselves.  I 
wonder  if  all  this  yellow  pigment  is  not  a  remnant  of  old  corpora  lutea  ? 

Fig.  77  is  also  drawn  from  nature,  in  actual  size,  and  shows  a  corpus  luteum 
transformed  into  a  cyst,  numerous  yellow  masses  with  remnant  of  a  central  cavity, 
and  two  corpora  nigra. 


76 


DISEASES  OF   WOMEN. 


FIG. 


Ovary  of  Woman  forty-sev- 
en years  old  (natural 
size):  a,  corpus  luteum 
with  central  cavity ;  6, 
another  corpus  luteum; 
c,  a  third  small  one:  be- 
sides this  thirteen  yellow 
bodies  could  be  counted 


in  the  invisible  parts  of 
the  ovary. 


it  follows   a   curved   course,   with    the   concavity   forward.      It    is 
imbedded  in  the  vaginal  wall. 

It  is  suspended  to  the  pubic  arch  by  the  pubo-vesical  ligament, 
and  passes  through  the  triangular  ligament, 
between  the  layers  of  which  it  is  surrounded 
by  the  compressor  urethras  muscle,  or  Outline's 
muscle.  Another  sphincter  muscle  surrounds 
the  urethra  and  the  vagina  together  as  a  nar- 
row belt  just  behind  the  vestibulo-vaginal  bulbs. 
The  urethra  has  an  outer  layer  of  circular 
unstriped  muscle-fibres,  an  inner  longitudinal 
layer,  and  a  mucous  membrane. 

The  meatus  urinarius  has  already  been  de- 
scribed in  speaking  of  the  vulva  (see  p.  39). 

The  mucous  membrane,  when  not  distended, 
forms  longitudinal  folds.  It  has  many  de- 
pressions and  blind  canals,  so-called  Morgag- 
ni's  lacunce,  and  racemose  glands  (Littre's l 
glands).  Near  the  floor,  just  inside  of  the 
meatus,  are  found  two  canals,  Skene's  glands* 
or  urethral  ducts  (Fig.  79),  one  on  either  side.  They  admit  a  No.  1 
probe  of  the  French  scale,  and  extend  upward,  parallel  to  the  long 

axis  of  the  urethra,  from  -|  to  ^  of 
an  inch,  in  the  muscular  tissue,  below 
the  mucous  membrane.  The  mouths 
of  these  tubules  are  found  upon  the 
latter  ^  of  an  inch  from  the  meatus. 
If  the  mucous  membrane  is  everted 
— which  it  often  is  in  those  who 
have  borne  children — the  openings 
are  exposed  to  view  on  either  side  of 
the  entrance  to  the  urethra.  The 
upper  end  of  these  tubes  terminates 
in  a  number  of  divisions  which  branch 
off  into  the  muscular  wall  of  the 
urethra. 

The  mucous  membrane  of  the 
urethra  is  of  pink  color,  surrounded  by  a  rich  network  of  veins,  and 
has  a  stratified  flat  epithelium. 

Vessels  and  nerves  are  derived  from  those  of  the  vagina. 

1  This  name  is  often  erroneously  spelt  Littre,  which  is  that  of  the  author  of  a 
dictionary,  just  as  Gartner  almost  invariably  is  called  Gartner,  and  Bartholin  often 
Bartholini.  Both  were  Danes. 

2Skene,  "The  Anatomy  and  Pathology  of  Two  Important  Glands  of  the  Female 
Urethra,"  Am.  Jour.  Obstet.,  1880,  vol.  xiii.  p.  265.  Their  glandular  nature  has 
been  contested. 


e 


Ovary  of  Woman  twenty-nine  years  old: 
a,  corpus  luteum  transformed  into 
cyst ;  b,  numerous  yellow  masses  with 
remnant  of  central  cavity  :  cc,  corpora 
nigra ;  </,  albuginea. 


ANATOMY. 


77 


Functions. — The  function  of  the  urethra  is  to  serve  as  an  outlet 
from  the  bladder.  Its  muscular  tissue  works  probably  as  a  sphincter 
for  the  same. 

FIG.  78. 


Adult  Ovary,  Parovarium,  and  Fallopian  Tube  (Kobelt) :  aa,  parqvarium  (or  epophoron);  b, 
remains  of  the  uppermost  tubes  of  the  Wolffiaii  body ;  c.  middle  set  of  tubes  forming 
parovarium  ;  d,  lower,  atrophied  tubes;  e,  atrophied  remains  of  Wolffian  duct  (Gartner's 
canal);/,  the  terminal  bulb  or  hydatid  of  the  Wolffiaii  duct;  h,  the  Fallopian  tube;  i, 
hydatid  of  Morgagni ;  I,  ovary. 

THE  BLADDER. 

The  bladder  is  a  hollow  muscular  organ  situated  in  the  median 
line,  between  the  pubic  bones  in  front  and  the  vagina  and  uterus 
behind.  When  empty,  it  is  in  the  true  pelvis ;  Avhen  distended,  it 
reaches  more  or  less  high  up  in  the  abdominal  cavity,  lying  close  up 
against  the  abdominal  wall.  When  empty,  it  has  been  found  in  two 
different  shapes — either  so  that  the  upper  part  falls  against  the  lower, 
the  cavity  combined  with  the  canS.1  of  the  urethra  having  the  shape 
of  a  Y,  of  which  the  two  upper  branches  represent  the  bladder,  and 
the  lower  trunk  the  urethra,  or  so  that  the  anterior  wall  comes  in 
contact  with  the  posterior.  In  the  latter  case  the  combined  lumen 
of  the  bladder  and  the  urethra  form  a  C  or  an  L.1 

The  female  bladder  is  shorter  than  the  male  in  the  antero-posterior 
direction,  but  more  than  makes  up  for  this  by  being  broader.  I  have 
myself  drawn  three  quarts  of  urine  from  a  woman  who  had  no  reten- 
tion of  urine,  and  I  have  read  that  four  litres  have  been  evacuated 
from  a  female  bladder.  When  distended  it  has  an  ovoid  shape. 

We  distinguish  the  base,  the  summit,  the  anterior  and  the  posterior 

1  Hart  and  Barbour  (Manual  of  Gynecology,  4th  ed.,  p.  35)  suggest  ingeniously 
that  the  Y-shape  is  that  of  relaxation,  and  that  the  oval  shape  represents  systole — 
i.  e.  contraction :  but  if  the  oval  shape  were  due  to  muscular  contraction,  it  could 
hardly  be  maintained  after  death. 


78 


DISEASES  OF   WOMEN. 


FIG.  79. 


surface,  and  two  sides.  The  base  orfundus1  is  the  lowest  part  of  the 
organ.  It  is  bound  by  rather  dense  connective  tissue  to  the  anterior 
wall  of  the  vagina  and  the  neck  of  the  womb.  Three  openings  are 
found  on  it.  In  front  is  the  internal  opening  of  the  urethra,  which 
is  flat,  crescent-shaped.  There  is  no  funnel-shaped  part  here,  so  that 
the  term  "  neck "  is  a  misnomer.  The  urethra  opens  abruptly  on 
the  wall  of  the  bladder.  Behind  there  are  two  fine,  lengthy  slits 
where  the  ureters  open  into  the  bladder.  The 
triangle  between  these  three  openings  is  called 
the  trigone  (Fig.  80).  Each  of  its  sides  meas- 
ures about  an  inch.  The  base  is  formed  by 
the  intra-ureteric  ligament.  The  distance  from 
this  to  the  cervix  uteri  varies.  I  have  found 
it  immediately  under  the  os  and  half  an  inch 
below  it.  When  the  bladder  is  distended  the 
distance  increases  to  1  inch. 

The  surface  on  which  the  bladder  is  in 
contact  with  the  vagina  is  heart-shaped.  The 
boundary-line  runs  in  the  lower  part  parallel 
to  and  a  little  outside  of  the  trigone.  In  the 
upper  part  it  follows  the  outline  of  the  vagina. 
The  bladder  extends  f  inch  up  on  the  cervix. 
From  the  summit  the  urachus,  one  of  the  false, 
ligaments  of  the  bladder,  goes  to  the  umbilicus. 
The  anterior  surface  lies  up  against  the  body 
of  the  pubic  bones  and  the  anterior  abdominal 
wall.  It  has  no  peritoneal  covering.  The 
posterior  wall  is  covered  with  peritoneum  down 
to  the  level  of  the  internal  os,  where  it  passes  over  on  the  uterus. 
Under  this  fold  lies  some  loose  connective  tissue.  The  sides  are  like- 
wise covered  with  peritoneum.  The  posterior  wall  is  alternately  in 
contact  with  the  uterus  or  the  small  intestine,  which  latter  likewise 
at  times  touches  the  sides.  The  wall  varies  in  thickness,  according  to 
the  degree  of  distension,  between  ^  and  J  inch.  It  is  composed  of 
a  serous,  a  muscular,  and  a  mucous  coat.  The  serous  coat  is  formed 
by  the  peritoneum.  During  pregnancy  the  connective  tissue  that  binds 
it  to  the  underlying  tissue  becomes  so  loose  that  during  labor  the  blad- 
der becomes  entirely  stripped  of  its  peritoneal  coat.  The  muscular 
coat  has  an  outer  longitudinal  and  an  inner  circular  layer  of  unstriped 
fibres.  When  the  bladder  is  much  distended,  the  bundles  can  be  seen 
to  separate  so  as  to  present  a  kind  of  lattice-work.  The  muscular  tissue 
is  thicker  around  the  opening  to  the  urethra,  which  disposition  prob- 
ably serves  to  press  out  the  last  drops  of  urine  during  micturition. 

1  The  reader  will  notice  that  in  speaking  of  the  bladder  the  word  "  fundus  "  is 
taken  in  an  entirely  different  sense  from  that  applied  to  the  uterus. 


The  Urethra  laid  open  from 
behind ;  probes  introduced 
into  the  urethral  ducts 
(Skene). 


ANATOMY. 


79 


The  mucous  membrane,  examined  with  the  galvanic  cystoscope, 
has  a  lively  pink  color.  In  general  it  is  loosely  attached  to  the 
muscular  layer,  and  forms  folds  when  the  bladder  is  empty.  But  at 


FIG.  80. 


Uterus,  Ureters,  and  Upper  Part  of  Vagina  of  Woman  forty  years  old,  j  natural  size.  All 
measurements  were  made  in  situ  with  compasses,  and  then  marked  on  the  paper  without 
regard  to  foreshortening :  a,  ureters  ;  6,  uterus ;  c,  Fallopian  tube  :  d.  ovary  ;  e,  round  liga- 
ment; .F,  broad  ligament;  g,  connective  tissue;  h,  bladder  (the  antero-superior  part  re- 
moved to  show  attachment  to  cervix  and  vagina);  i,  vesical  opening  of  ureters;  j.  inner 
aperture  of  urethra ;  k,  urethra  ;  t,  vagina ;  m,  incision  and  rent  in  the  operation  called 
gastro-elytrotomy  as  originally  performed  by  Baudelocque. 

the  trigone  it  is  attached  more  solidly.  It  contains  numerous  lacuna? 
and  racemose  glands.  It  is  covered  with  a  transition  epithelium,  in 
which  several  layers  are  discernible,  an  upper  of  flat  and  several 
deeper  of  large  and  small  pear-shaped  cells  (Figs.  81,  82).  The 
mucous  membrane  seems  to  be  able  to  absorb  substances  injected  into 
the  bladder. 

Between   the   mucous    membrane   and   the   muscular   coat   there 


80  DISEASES  OF   WOMES. 

is,  with  the  exception  of  the  trigone,  a  well-developed  submucous 
layer  composed  of  connective  tissue,  elastic  fibres,  vessels,  and 
nerves. 

Ligaments. — The  bladder  has  four  true  and  five  false  ligaments. 
The  true  are  thickened  parts  of  the  pelvic  fascia.  The  anterior  true 
ligaments  are  two  in  number,  a  narrow  but  strong  band  on  each  side, 
consisting  to  a  great  extent  of  involuntary  muscle-fibers,  and  passing 
from  the  lower  part  of  the  pubis  to  the  anterior  surface  of  the  blad^ 

FIG.  81.  FIG.  82. 


X350.  W   \U®      VX350 


FIG.  81.— Superficial  Layer  of  the  Epithelium  of  the  Bladder,  front  view,  composed  of  poly- 
hedral cells  of  various  sizes,  with  one,  two,  or  three  nuclei  (Klein  and  Noble  Smith). 


FIG.  82.— Deep  Layers  of  Epithelium  of  Bladder,  side  view,  showing  large  club-shaped  cells 
above  and  smaller,  more  spindle-shaped,  cells  below,  each  with  an  oval  nucleus  (Klein 
and  Noble  Smith). 

der,  above  the  urethral  opening.  On  the  outer  side  of  the  anterior 
ligament  the  part  of  the  fascia  which  descends  to  the  side  of  the 
bladder  is  known  as  the  lateral  true  ligament. 

The  false  vesical  ligaments  are  folds  of  the  peritoneum.  There 
are  two  posterior,  two  lateral,  and  one  superior.  The  posterior  are 
the  vesico-uterine  ligaments  (see  p.  55) ;  the  lateral  false  ligaments 
extend  from  the  iliac  fossae  to  the  sides  of  the  bladder,  each  separated 
from  the  posterior  ligament  by  the  obliterated  hypogastric  artery. 
The  superior  false  ligament  (ligamentum  suspensorium)  is  the  portion 
of  peritoneum  between  the  ascending  parts  of  the  hypogastric  arteries, 
and  reaches  from  the  summit  of  the  bladder  to  the  umbilicus.  It 
covers  the  urachus,  a  fibrous  cord  which  lies  between  the  linea  alba 
and  the  ligamentum  suspensorium. 

The  urachus  is  a  remnant  of  the  atlantoid  of  fetal  life,  and  has  pre- 
served a  long  cavity,  subdivided  by  partitions  and  lined  with  epithe- 
lium similar  to  that  of  the  bladder.  Sometimes  this  cavity  commu- 
nicates with  the  bladder. 

Vessels  and  Nerves. — The  arteries  come  directly  from  the  internal  iliac 
(the  superior,  middle,  and  inferior  vesical  arteries)  or  from  its  branches, 
the  sciatic,  internal  pudic,  middle  hemorrhoidal,  and  uterine  arteries. 
The  veins  form  large  plexuses  communicating  with  those  of  the  uterus, 
vagina,  vulva,  and  rectum,  and  sending  their  blood  to  the  internal 
iliac  vein.  The  lymphatics  follow  the  veins  and  open  into  the  hypo- 


ANATOMY.  81 

gastric  glands.     The  nerves  come  from  the  hypogastric  plexus  of  the 
sympathetic  and  the  sacral  nerves  (cerebro-spinal). 

Function. — The  bladder  serves  as  a  reservoir  for  the  urine,  which 
is  intermittently  thrown  into  it  from  the  ureters.  It  is  emptied  by 
the  contraction  of  its  own  muscle-fibers,  while  the  sphincters  are  placed 
in  the  urethra. 

THE    URETERS.1 

There  are  two  ureters,  long,  slender  cylindrical  tubes,  leading  from 
the  kidneys  to  the  bladder.  They  are  16  to  18  inches  long,  and 
thick  as  a  goose-quill  in  circumference.  They  are  the  continuation 
of  the  renal  pelvis.  They  lie  behind  the  peritoneum,  imbedded  in  very 
loose  connective  tissue,  and  are  much  longer  than  the  direct  line  be- 
tween their  two  ends.  At  their  upper  ends  the  distance  between  them 
is  2J  inches.  From  this  point  they  go,  excepting  slight  windings, 
parallel  with  one  another,  down  to  the  spot  where  they  cross  the  iliac 
vessels  at  the  brim  of  the  pelvis.  In  this  part  of  their  course  they  lie 
in  front  of  the  psoas  muscle.  They  are  crossed  about  midway  by  the 
ovarian  vessels ;  the  right  lies  close  to  the  outer  side  of  the  inferior 
vena  cava,  behind  the  ileum.  The  left  lies  behind  the  sigmoid  flex- 
ure of  the  colon.  They  cross  the  lower  end  of  the  common  iliac  artery 
or  the  upper  end  of  one  of  its  two  branches,  the  external  and  the  in- 
ternal iliac  (Fig.  83),  and  enter  the  pelvis.  Here  they  describe  a  large 
curve.  First  they  diverge,  running  downward,  backward,  and  a  little 
outward  on  the  wall  of  the  pelvis  to  a  point  near  the  spine  of  the 
ischium ;  then  they  bend  downward,  forward,  and  considerably  in- 
ward, so  as  to  converge  toward  the  bladder.  They  lie  outside  of  the 
internal  iliac  artery,  behind  the  broad  ligaments,  running  down  to 
their  base,  and  then  under  them,  and  at  the  brim  of  the  pelvis  they 
lie  behind  the  ovarian  vessels  where  these  turn  inward  through  the 
infundibulo-pelvic  ligament.  They  go  right  through  the  large  plexus 
of  veins  found  at  the  sides  of  the  cervix  uteri  (Fig.  57,  p.  61),  behind 
the  loop  formed  by  the  uterine  artery  (Fig.  56,  p.  60).  They  cross 
the  cervix  at  the  distance  of  about  \  inch,  from  behind,  at  an  acute 
angle,  so  as  to  come  in  front  of  and  below  it.  On  reaching  the  wall 
of  the  bladder  they  turn  rather  sharply  inward,  run  for  J  inch  in  the 
wall,  perforating  it  gradually,  and  open  with  a  small  longitudinal  slit 
in  the  interior  of  the  bladder.  But  their  substance  is  continued  from 
side  to  side  as  the  interureteric  ligament,  a  ridge  that  forms  the  base 
of  the  trigone. 

1  The  knowledge  of  the  topography  of  the  ureter  has  acquired  special  importance 
in  regard  to  the  extirpation  of  the  uterus.  The  questions  involved  have  been  inves- 
tigated by  Polk  and  myself,  separately  and  conjointly  (Polk,  N.  Y.  Med.  Jour.,  May, 
1892,  vol.  xxxv.  pp.  451-53;  Garrigues,  on  "  Gastro-elytrotomy,"  New  York,  Apple- 
ton,  1878,  pp.  67-74,  also  N.  Y.  Med.  Jour.,  Nov.,  1878)  ;  Garrigues,  "Additional 
Eemarks  on  Gastro-elytrotomy,"  Amer.  Jour.  Obstel.,  1883,  vol.  xvi.  pp.  45-49). 


82 


DISEASES  OF  WOMEN. 


In  crossing  the  cervix  the  ureters  lie  outside  and  above  the  anterior 
part  of  the  side  wall  of  the  vagina  on  a  spot  as  large  as  the  tip  of  the 
finger. 

During  pregnancy  the  course  of  the  ureters  undergoes  a  great 
change.  Its  middle  part,  that  which  in  the  un impregnated  condition 
sinks  down  to  the  spine  of  the  ischium,  is  lifted  up,  together  with  the 
broad  ligaments.  From  the  point  where  the  ureter  crosses  the  iliac 
arteries  it  goes  forward,  downward,  and  outward,  lying  immediately 
under  the  peritoneum,  on  the  wall  of  the  false  pelvis.  A  little  behind 

FIG.  83. 


The  Course  of  the  Ureters,  from  a  woman  fifty-seven  years  of  age,  with  atrophic  uterus,  \  nat- 
ural size.  Specimen  drawn  in  situ.  Ureters  laid  bare  from  the  place  where  they  cross 
the  iliac  vessels  to  the  place  where  they  pass  under  the  broad  ligaments.  Bladder  dis- 
sected from  uterine  neck  and  upper  part  of  the  vagina  and  drawn  down  in  order  to  show 
the  curve  of  the  ureters  and  the  trigone.  The  oroad  ligaments  have  been  removed 
and  the  bladder  cut  in  the  median  line,  so  as  to  show  the  inside  of  it :  a,  ureter;  b,  com- 
mon iliac  artery  ;  c,  external  iliac  artery ;  d,  internal  iliac  artery  ;  e,  uterus  (appendages 
cut  off ) ;  /,  bladder ;  g,  site  of  vesical  ap'erture  of  ureter  on  the  inner  surface  ot  bladder 
(not  visible) ;  h,  vesical  aperture  of  urethra  ;  i,  base  of  trigone  (interureteric  ligament) ; 
j,  incision  in  bladder ;  k,  vagina. 

the  end  of  the  transverse  diameter  of  the  pelvis  the  ureter  dips  down 
into  the  true  pelvis,  and  goes  in  a  curved  line  inward,  forward,  and 
downward  till  it  reaches  the  bladder.  In  this  way  it  passes  under 
the  broad  ligaments,  and  in  front  of  these  it  lies  again  immediately 
under  the  peritoneum.  From  the  point  where  it  opens  into  the  blad- 


ANATOMY. 


83 


FIG.  84. 


der  to  the  posterior  surface  of  the  pubis  behind  the  spine  is  a  distance 
of  3  inches.  It  will  thus  be  seen  that  while  the  posterior  part  of  the 
course  of  the  ureter  through  the  pelvis  is  lifted  up  to  so  high  a  level, 
the  anterior  end  retains  its  position. 

Structure. — The  ureters  have  a  fibrous  coat,  a  muscular  coat,  with 
an  outer  circular  and  an  inner  longitudinal  layer,  and  a  mucous 
membrane,  with  a  transition  epithelium  composed  of  an  inner  short 
layer,  a  middle  columnar  with  long  processes,  and  a  deep  layer  of 
more  round  smaller  cells  (Fig.  84).  The  cells  of  the  deeper  layers 
resemble  those  in  the  deeper  layers 
of  the  bladder  epithelium  very  much. 
When  not  distended  the  mucous  mem- 
brane forms  longitudinal  folds.  It  has 
no  glands. 

Vessels  and  Nerves. — The  ureters  re- 
ceive arteries  from  the  renal,  ovarian, 
internal  iliac,  and  vesical  arteries.  The 
veins  correspond  to  the  arteries.  The 
lymphatics  lead  to  the  lumbar  glands. 
The  nerves  come  from  the  sympathetic. 

Function. — The  ureters  lead  the  urine 
from  the  kidneys  to  the  bladder.  In 
cases  of  extroversion  of  the  bladder  or 
of  large  vesico-vaginal  fistulse,  it  can  be 
seen  how  the  urine  is  spurted  out  with 
pretty  regular  intermissions.  That  the 
ureters  may  become  much  distended  by 
accumulated  urine  may  be  concluded 
from  the  fact  that  if  the  bladder  has 
been  overfilled  and  is  emptied,  fresh  de- 
sire for  emptying  it  recurs  soon,  and 
gives  issue  to  a  disproportionately  large 
amount  of  urine.  The  ureters  are  kept 
closed  by  the  elastic  tension  in  the  mus- 
cle-fibres which  surround  them,  while 

they  perforate  the  bladder,  which  tension  is  overcome  when  the  pres- 
sure reaches  a  certain  point. 

THE   RECTUM. 

The  rectum  is  the  lowest  division  of  the  intestine,  extending  from  the 
colon  to  the  anus.  Although  the  word  "  rectum  "  means  straight,  the 
intestine  curves  and  bends  so  as  to  form  three  distinct  parts.  It  enters 
the  pelvis  in  front  of  the  left  ilio-sacral  articulation  (Fig.  53,  p.  56),  goes 
first  downward,  backward,  and  inward,  in  front  of  the  third  or  fourth 
sacral  vertebra,  to4he  median  line  ;  here  it  turns  forward  and  lies  in  con- 


Epithelium  of  Pelvis  of  Kidney  of 
man  X  350  (Kolliker;:  A,  single 
cells  ;  B,  the  same,  in  situ  ;  a,  small 
flat  cells:  6,  large  flat  cells  ;  c,  simi- 
lar ones  with  bodies  like  nuclei  in 
the  interior ;  d,  cylindrical  and 
cone-shaped  cells  from  the  deeper 
layers ;  e,  transitional  forms. 


84 


DISEASES  OF  WOMEN. 


tact  with  the  cervix  and  the  vagina  (Fig.  50,  p.  54) ;  finally,  an  inch 
from  its  end  it  turns  rather  sharply  downward  and  backward  at  a 


FIG.  85. 


Rectum  inflated  with  Air  (Chadwick) :  D,  D',  anterior  and  posterior  segments  of  the  superior 
detrusor  feecium  (so-called  third  sphincter) ;  B,  rectal  ampulla ;  f  and  *.  the  same  points 
so  marked  in  Fig.  88. 

right  angle  with  the  second  part.     This  last  part  is  called  the  anal 
canal  (Figs.  50,  p.  54,  and  34,  p.  42),  and  is  the  narrowest  por- 


AX  ATOMY. 


85 


tion,  while  the  part  situated  immediately  above  it  is  the  widest,  and 
is  called  the  rectal  ampulla.  From  here  the  gut  tapers  gradually  to 
the  upper  end  (Fig.  85).  It  is  about  8  inches  long,  and  when  empty 


FIG. 


The  Lower  End  of  the  Rectum  in  Vertical  Section  (Rydygier)  :  1,  rectal  mucous  membrane; 
2,  line  of  separation  between  mucous  membrane  and  skin  of  buttock ;  3,  fat ;  4,  levator 
ani  muscle;  5,  6,  external  sphincter;  7,  internal  sphincter;  8,  9,  longitudinal  muscular 
fibers  interlacing  with  those  of  sphincter;  10,  filiform  terminations  of  longitudinal  fibers; 
11,  circular  fibers ;  12, 13,  longitudinal  fibers  of  muscularis  mucosse. 

about  1J  inches  from  edge  to  edge,  but  capable  of  such  a  distention 
that  it  sometimes  nearly  fills  the  pelvic  cavity.  The  way  in  which 
it  collapses  when  empty  depends  probably  on  the  condition  of  the 
vagina  and  the  bladder.  If  these  are  empty,  the  rectum  collapses 
from  side  to  side  (Fig.  35,  p.  43),  but  if  the  other  cavities  are  dis- 
tended, it  becomes  compressed  in  an  antero-posterior  direction. 


86 


DISEASES  OF  WOMEN. 


Structure. — The  rectum  is  composed  of  a  peritoneal  coat,  a  muscular 
coat,  and  a  mucous  membrane.  In  regard  to  its  relation  to  the  peri- 
toneum, it  may  be  divided  into  three  parts :  the  upper  is  completely 
covered,  and  has  even  sometimes  a  mesorectum ;  the  middle  is  cov- 


FIG.  87. 


Muscles  of  the  Perineum  (Breisky) :  1,  glans  clitoridis ;  2,  corpus  clitorldis ;  3,  meatus  urin- 
arius;  4,  tendon  of  ischio-cavernosus  muscle;  5,  bulb;  6,  ischio-cavernosus  muscle;  7, 
vaginal  entrance  :  8,  sphincter  vaginae  or  bulbo-cavernosus  muscle  ;  9,  fossa  navicularis 
10,  Bartholin's  gland  ;  11,  superficial  transversus  perinsei  muscle ;  12,  anus ;  13,  sphincter 
ani  externus;  14,  15,  levator  ani  muscle;  16,  coccygeus  muscle;  17,  great  sacro-sciatic 
ligament ;  18,  obturator  internus  muscle ;  19,  glutseus  maximus  ;  20,  os  coccygis. 

ered  with  peritoneum  in  front  only  (Douglas's  pouch) ;  and  the  third 
has  no  peritoneal  covering  at  all.  The  last  part  measures  1£  to  2 
inches  from  the  anal  opening.  ,  . 

The  muscular  coat  has  an  outer  longitudinal  and  an  inner  circular 
layer.  The  longitudinal  layer  is  spread  all  over,  and  does  not  form 
such  bands  as  on  the  colon.  Besides  this,  the  mucous  membrane  con- 


AX  ATOMY.  87 

tains  a  layer  of  longitudinal  fibers.  At  the  lower  end  all  the  longi- 
tudinal fibers  are  intimately  interlaced  with  certain  other  muscles  that 
are  attached  to  the  rectum — the  levator  ani  muscle,  the  external 
sphincter  ani  muscle,  and  the  internal  sphincter  ani  muscle — and  can 
be  followed  down  through  them  to  the  skin  (Fig.  86). 

The  external  sphincter  ani  muscle  (Figs.  87,  13)  is  an  elliptic  layer 
of  striped  muscular  fibers  which  surround  the  anal  opening  and  lie 
directly  under  the  skin.  Behind  it  is  fastened  with  a  tendon  to  the 
tip  of  the  coccyx ;  in  front  it  blends  with  the  transversus  perinei  and 
sphincter  vagina?  muscles.  It  is  the  true  voluntary  sphincter  by 
which  faeces  and  gases  are  kept  back. 

The  internal  sphincter  ani  muscle  is  only  a  thicker  part  of  the  cir- 
cular layer  of  the  rectum  situated  inside  of  the  external  sphincter,  and 
consists  of  unstriped  muscle-fibres,  with  a  considerable  admixture  of 
striped  fibers.  It  gets  fibers  from  the  deep  layer  of  the  deep  perineal 
fascia,  from  the  superficial  trausversus  periuei,  and  from  the  bulbo- 
cavernosus  muscles.  It  surrounds  the  anal  canal,  and  is  an  inch 
high.  It  contracts  and  relaxes  by  reflex  action,  and  is  not  subject  to 
the  will. 

The  levator  ani  muscle  (Figs,  87,  14,  15)  forms  an  important  part 
of  the  pelvic  floor,  and  will  be  considered  under  that  heading. 

The  mucous  membrane  shows  numerous  folds.  In  the  lower  part 
of  the  rectum  these  have  a  longitudinal  direction,  and  are  called  the 
columns  of  Morgagni,  and  the  depressions  between  them  are  called 
the  sinuses  of  Morgagni.  In  the  upper  part  transverse  folds  prepon- 
derate. Three  of  these  (more  rarely  only  two  or  one),  situated  within 
reach  of  the  examining  finger,  are  particularly  developed,  and  called 
Houston's  valves.  Commonly  one  of  them  is  placed  on  the  anterior 
wall,  about  2  inches  above  the  anus ;  the  others  an  inch  higher  up, 
on  the  posterior  wall.  They  are  semicircular,  and,  the  transverse 
muscles  extending  from  one  to  the  other  (Fig.  88),  they  form  together 
a  kind  of  circular  valve,  which  ordinarily  lies  below  the  accumulated 
feces.  This  apparatus  has  been  described  as  a  third  sphincter,  but  is, 
according  to  Chad  wick,  a  detrusor ;  that  is,  it  serves  to  expel  the  feces.1 

The  mucous  membrane  is  covered  with  columnar  epithelium  and 
has  many  glandular  pouches.  The  transition  from  the  skin  to  the 
mucous  membrane  is  distinctly  marked  by  a  so-called  white  line. 

Relations. — The  rectum  lies  in  contact  outside  with  the  left  ureter 
and  left  internal  iliac  artery.  It  has  the  left  ovary  in  front,  and  rests 
on  the  pyriformis  muscle  and  the  sacral  plexus.  It  is  bound  to  the 
sacrum  by  the  mesorectum  in  the  upper  part,  and  by  fibrous  connect- 
ive tissue  and  fat  lower  down.  It  lies  in  the  gap  left  between  the 


1  J.  K.  Chadwick,  "  The  Functions  of  the  Anal  Sphincters,  so-called,  and  the  Act 
of  Defecation,"  Trans.  Am.  Gyn.  Soc.,  ii.  pp.  43-56.  I  have,  however,  frequently 
palpated  these  folds  on  patients,  and  do  not  find  that  it  causes  any  expulsive  effort. 


88 


DISEASES  OF  WOMEN. 


sacro-uterine  ligaments.  Loops  of  the  small  intestine  lie  between  its 
upper  part  and  the  uterus,  unless  the  latter  be  pushed  far  back  by  an 
overfilled  bladder.  In  the  narrow  lower  part  of  Douglas's  pouch 
there  are,  as  a  rule,  no  intestines ;  the  rectum  hugs  the  cervix  and 
lies  close  up  to  the  vagina.  The  anal  canal  forms  the  posterior  wall 


FIG.  88. 


Rectum  cut  open  longitudinally,  and  the  mucous  membrane  dissected  off,  so  as  to  show  the 
circular  muscular  fibres  (Chadwick) :  DD1,  anterior  and  posterior  segment  of  the  superior 
detrusor  fsecium  (or  third  sphincter) ;  S,  inferior  detrusor  fsecium  (or  internal  sphincter); 
A,  anus;  t  and  *  correspond  to  the  same  points  in  Fig.  85.  This  drawing  shows  the  mus- 
cular fibres  passing  from  the  anterior  to  the  posterior  segment  of  the  superior  detrusor,  by 
the  action  of  which  they  may  be  approximated  to  each  other. 

of  the  perineal  body,  which  separates  it  from  the  entrance  to  the 
vagina  and  the  vulva. 

Vessels  and  Nerves. — The  rectum  has  an  abundant  blood-supply. 
The  arteries  are  the  superior  hemorrhoidal  from  the  inferior  mesen- 
teric,  the  middle  hemorrhoidal  from  the  internal  iliac  or  one  of  its 
branches,  a  branch  of  the  middle  sacral,  and  the  inferior  hemorrhoidal 


ANATOMY.  89 

from  the  internal  pudic.  The  veins  form  a  rich  plexus,  and  lead  the 
blood  through  the  inferior  and  middle  hemorrhoidal  to  the  internal 
iliac,  and  through  the  superior  hemorrhoidal  to  the  superior  mes- 
enteric,  a  branch  of  the  vena  porta.  The  lymphatics  go  to  the  sacral 

FIG.  89. 


Pelvic  Peritoneum  with  Empty  Bladder ;  mesial  section  of  frozen  body,  J  (Fiirst).  The  dotted 
line  indicates  the  peritoneum ;  a,  rectum ;  6,  vagina ;  c,  bladder ;  d,  uterus ;  e,  below  pouch 
of  Douglas ;  /,  symphysis  pubis. 

glands.  The  nerves  come  partly  from  the  sympathetic  nerve  (the 
hypogastric  plexus),  partly  from  the  cerebro-spiual  system  (sacral 
plexus). 

Function. — The  rectum  is  a  receptacle  for  the  feces,  and  expels 


90 


DISEASES  OF  WOMEN. 


them  by  the  combined  action  of  its  circular  and  longitudinal  fibers, 
the  first  contracting  above  and  relaxing  below  the  mass  to  be  removed, 
and  the  latter  preventing  sacculation,  straightening  the  canal,  and 
pulling  the  relaxed  part  of  the  intestine  up  over  the  fecal  mass.  The 
internal  sphincter  can,  by  its  contraction,  push  the  mucous  membrane 
out  through  the  anus,  and  thus  becomes  an  expulsive  muscle,  as  is 
veiy  apparent  in  the  horse.  The  mucous  membrane  is  capable  of 
absorbing,  which  explains  many  bad  effects  of  constipation,  and  is 
utilized  for  the  administration  of  drugs  and  artificial  alimentation. 

THE  PELVIC  PERITONEUM. 

The  pelvic  peritoneum  is  a  continuation  of  the  abdominal  perito- 
neum, and  covers  the  organs  in  the  pelvis  more  or  less  completely. 

FIG.  90. 


Diagram  designed  to  show  the  antero-posterior  outline  of  the  pelvic  peritoneum  in  the  mesial 
pelvic  plane,  with  distended  bladder  (Ranney):  PP,  peritoneum ;  B,  rectum;  U,  uterus; 
B,  bladder ;  S,  symphysis  pubis.  The  vesico-abdominal,  the  vesico-uterine,  and  Douglas  s 
pouch  are  made  very  apparent. 

It  has  been  likened  to  a  cloth  which  is  being  lifted  up  by  pushing 
the  organs  from  below  up  under  it,  by  which  they  themselves  acquire 
a  covering  and  certain  folds  and  pouches  are  formed.  Thus  the  reader 
may  imagine  that  the  peritoneum  is  represented  by  a  sheet  of  thin 
muslin,  and  that  an  apple  representing  the  bladder,  a  pear  represent- 
ing the  uterus,  and  a  banana  representing  the  rectum  are  placed  under 


ANATOMY.  91 

it.  Beginning  in  front,  the  peritoneum  passes  from  the  anterior 
abdominal  wall  at  the  upper  end  of  the  symphysis  pubis  over  on  the 
top  of  the  bladder  (Fig.  89),  covers  its  posterior  wall  down  to  the 
level  of  the  internal  os  of  the  uterus,  and  its  sides  behind  the  oblit- 
erated hypogastric  artery.  When  the  bladder  is  much  distended  it 
rises  up  into  the  abdominal  cavity,  and  the  peritoneum  forms  a  pouch 
between  the  abdominal  wall  and  the  bladder  (the  vesico-abdominal 
pouch),  the  deepest  point  of  which  lies  an  inch  above  the  symphysis 
(Fig.  90). 

From  the  posterior  surface  of  the  bladder  the  peritoneum  passes 
over  on  the  anterior  wall  of  the  uterus,  covering  it  entirely  above  the 
cervix,  and  leaving  a  pouch  between  the  two  called  the  vesico-uterine 
pouch.  When  the  bladder  is  over-distended,  the  bottom  of  this 
pouch  is  raised  a  little,  as  represented  in  the  figure.  Next,  the  peri- 
toneum covers  the  whole  posterior  surface  of  the  uterus,  and  goes 
even  generally  an  inch  down  behind  the  posterior  wall  of  the  vagina, 
and  passes  then  over  on  the  rectum,  leaving  a  pouch  between  the  two 
called  Douglas's  pouch  or  the  recto-uterine  pouch.  This  pouch  varies 
very  much  in  depth,  sometimes  ending  at  the  posterior  utero-vagi- 
nal  junction,  and  in  other  cases  extending  down  as  far  as  the 
entrance  of  the  vagina.  Next,  the  peritoneum  covers  the  anterior 
surface  of  the  middle  portion  of  the  rectum,  surrounds  the  whole 
upper  portion  of  the  same,  and  passes  over  on  the  sacrum  as  the  meso- 
rectum. 

From  the  sides  of  the  uterus  the  peritoneum  passes  out  to  the  wall 
of  the  pelvis,  forming  the  broad  ligaments,  which  cover  the  Fallopian 
tubes,  the  round  ligaments,  the  ovarian  ligaments,  and  the  attached 
border  of  the  ovaries. 

The  uterus  and  the  broad  ligaments  together  form  a  partition  which 
divides  the  pelvic  cavity  into  an  anterior  inferior  and  a  posterior 
superior  part  (Fig.  52,  p.  55).  The  anterior  compartment  as  a  whole 
is  called  the  utero-abdominal  pouch.  In  it  we  notice  the  utero-vesical 
ligaments  and  the  round  ligaments  of  the  uterus.  It  is  filled  by  the 
bladder,  and,  when  this  is  empty,  by  loops  of  the  small  intestine.  Its 
lateral  parts,  where  the  entrance  is  to  the  obturator  canal,  have  been 
designated  as  the  obturator  pouch,  or  paravesical  pouch  (Fig.  91,  II). 
When  the  bladder  is  moderately  filled,  the  loops  of  the  small  intestine 
are  found  in  the  upper  part  of  the  utero-vesical  pouch. 

The  posterior  compartment  may  be  subdivided  into  a  central  deep 
part — i.  e.  Douglas's  pouch — and  two  shallower  lateral  parts  called 
para-uterine  pouches  (Fig.  91, 1).  The  bottom  of  the  latter  has  been 
designated  particularly  as  the  retro-ovarian  shelves  (Polk).  The 
boundary-line  between  these  three  parts  is  the  sacro-uterine  ligaments. 
On  the  side  wall  of  the  para-uterine  pouch  is  seen  the  ureter  running 
under  the  peritoneum  (Fig.  53,  p.  56).  The  ovaries  project  into 


92  DISEASES  OF  WOMEN. 

them,  and  they  contain  loops  of  the  small  intestine.     These  are  like- 
wise found  in  the  upper  part  of  Douglas's  pouch. 

About  the  elevation  of  the  peritoneum  during  pregnancy,  see  the 
description  of  the  broad  ligaments  and  the  ureters,  pp.  57  and  82.) 
The  para-uterine  pouch  is  lifted  up  to  the  pelvic  brim ;  the  para- 

FIG.  91. 


Position  of  Viscera  at  the  Pelvic  Brim  (Hasse) :  v,  bladder ;  «,  uterus ;  t,  tube ;  o,  ovary ;  c, 
caecum  :  r,  rectum;  Ir,  round  ligament;  pv,  appendix  vermiformis ;  d,  Douglas's  pouch  ; 
jyu,  fold  covering  ureter;  I,  para-uterine  pouch;  II,  para-vesical,  or  obturator  pouch; 
ip,  infundibulo-pelvic  ligament;  s.  i,  small  intestine. 

vesical  pouch  is  only  lifted  in  its  posterior  part ;  and  Douglas's 
pouch  is  not  interfered  with. 

The  parts  that  have  no  peritoneal  covering  are  the  anterior  wall 
of  the  bladder,  the  anterior  surface  and  the  sides  of  the  cervix  uteri, 
the  whole  lower  part  of  the  rectum,  and  the  posterior  portion  of  the 
middle  part  of  the  same. 

Function. — The  function  of  the  peritoneum  is  to  allow  free;  smooth 
movement  between  the  viscera.  It  presents  a  large  surface,  with 
great  power  of  absorption. 


ANATOMY. 


93 


THE  PELVIC  CONNECTIVE  TISSUE. 

The  dense  connective  tissue  forming  true  ligaments  or  fasciae  has 
already  been  considered,  or  will  be  considered  in  describing  the  pelvic 
floor.  Here  we  have  only  in  view  the  loose  connective  tissue,  which 
is  found  everywhere  underlying  the  peritoneum  in  larger  or  smaller 
quantity,  and  forming  one  continuous  layer,  which  is  a  continuation 
of  the  corresponding  layer  of  the  adjacent  parts.  In  some  places  it 
contains  fat.  Just  above  the  symphysis  pubis,  behind  the  linea  alba, 
is  found  a  considerable  layer  of  adipose  tissue,  the  preperitoneal  fat, 
which  constitutes  an  important  landmark  in  the  performance  of  lapa- 

FIG.  92. 


Coronal  Section  of  Pelvis,  showing  the  three  cavities  of  the  pelvis :  the  peritoneal,  the  sub- 
peritoneal,  and  the  subcutaneous  (Luschka). 

rotomy.  It  is  continued  behind  the  symphysis  as  retro-pubic  fat 
(Fig.  89),  and  lies  here  in  front  of  the  bladder.  Between  the  base 
of  the  bladder  and  the  vagina  the  connective  tissue  is  rather  tight. 
On  the  posterior  surface  of  the  vagina  there  is  a  very  loose  layer.  A 
large  mass  is  found  on  both  sides  of  the  cervix  uteri  (Fig.  92),  form- 
ing under  the  broad  ligaments  the  parametria,  which  are  united  by  a 
thinner  portion  in  front  and  behind.  On  the  body  of  the  uterus  there 
is  only  very  short  connective  tissue  without  fat,  but  during  pregnancy 
it  becomes  much  looser  and  increases  in  bulk.  The  rectum  and  the 
vagina  are  again  imbedded  in  considerable  masses  of  fatty  connective 


94  DISEASES  OF  WOMEN. 

tissue.  At  the  posterior  fornix  the  distance  between  the  vagina  and 
the  peritoneal  cavity  does  not  exceed  one-third  of  an  inch.  From  the 
uterus  and  the  parametrium  a  thin  layer  extends  between  the  two 
layers  of  the  peritoneum  which  form  the  broad  ligaments,  and  is  here 
mixed  with  many  elastic  fibers  and  unstriped  muscle-fibers.  From 
here  it  is  again  continued  up  into  the  iliac  fossae  and  the  lumbar 
region,  and  forward  and  backward  along  the  pelvic  wall. 

The  chief  bulk  of  the  subperitoueal  connective  tissue  forms  a  fun- 
nel-shaped mass  around  the  cervix  and  downward  around  the  vagina 
to  the  insertion  of  the  levator  ani  muscle  (see  Figs.  92  and  97). 

Function. — The  function  of  the  connective  tissue  is  to  fill  out  all 
free  spaces  between  the  organs,  to  furnish  a  soft  padding  around 
organs  of  very  changeable  size,  and  to  be  the  carrier  of  vessels  and 
nerves. 

THE  PELVIC  FLOOR. 

The  pelvic  cavity  may  be  divided  into  three  well-marked  subdi- 
visions :  the  pelvi-peritoneal  cavity,  the  subperitoneal  space,  and  the 
subcutaneous  space  (Fig.  92).1 

Of  these  we  have  already  described  the  first  and  the  second.  The 
boundary-line  between  the  second  and  the  third  is  a  muscular  dia- 
phragm— the  levator  ani  muscle — which  is  covered  above  and  below 
with  a  fascia,  and  has  openings  for  the  passage  of  the  urethra,  the 
vagina,  and  the  rectum. 

We  shall  now  consider  what  remains  to  be  studied  under  the  three 
headings — the  pelvic  fascia,  the  pelvic  diaphragm,  and  the  perineal 
region. 

I.  The  pelvic  fascia  (Fig.  93)  is  a  continuation  of  the  iliac  fascia. 
It  is  attached  to  the  iliac  part  of  the  ilio-pectineal  line  and  to  an 
oblique  line  on  the  posterior  surface  of  the  body  of  the  pubic  bone, 
extending  from  the  upper  and  inner  part  of  the  obturator  foramen  to 
a  point  a  little  below  the  symphysis.  At  the  upper  end  of  the  said 
foramen  it  leaves  an  opening  free  for  the  obturator  canal.  It  descends 
on  the  inside  of  the  bodies  of  the  ilium  and  ischium,  about  halfway 
down  the  pelvic  wall,  where  a  strong  sinewy  cord,  the  so-called 
tendinous  arch,  extends  from  the  spine  of  the  ischium  to  the  pubic 
bone  just  inside  of  the  obturator  canal  (Fig.  94).  This  part  of  the 
pelvic  fascia  covers  the  obturator  internus  muscle,  and  is  also  called 
the  obturator  fascia.  It  sends  a  thinner  prolongation  backward, 
covering  the  pyriformis  muscle,  and  called  the  pyriformis  fascia. 
At  the  tendinous  arch  the  pelvic  fascia  is  split  into  two  layers,  an 
upper  layer  called  the  vesico-rectal  fascia,  which  bends  inward  over 
the  levator  ani  muscle,  and  a  lower  layer,  which  continues  to  follow 

1  The  distinction  was  made  by  Luschka,  but  his  names,  cavum  peritoneale,  cavum 
subperitoneale,  and  cavum  subcutaneum  are  bewildering,  the  two  latter  "  cavities  " 
being  filled  with  solid  tissue. 


ANATOMY. 


95 


the  obturator  interims  muscle  down  to  the  inner  edge  of  the  ischio- 
pubic  branches,  and  keeps  the  name  of  obturator  fascia.  Just 
below  the  insertion  of  the  levator  ani  muscle  this  fascia  gives  off 
another  investment  of  this  muscle,  called  the  anal  fascia.  Together 
with  that  part  of  the  obturator  fascia  situated  below  the  tendinous 
arch  it  forms  the  lining  of  the  ischio-rectal  fossa. 

FIG.  93. 


Fascia  of  Pelvic  Floor  (Savage):  B,  bladder;  V,  vagina;  R,  rectum;  P,  symphysis  publs; 
S,  sacrum;  a,  fascia  covering  psoas  muscle;  b,  obturator  fascia;  c,  tendinous  arch:  d, 
reflection  of  fascia  on  to  the  rectum,  vagina,  and  bladder ;  e,  posterior  portion  of  fascia 
covering  sacral  vessels  and  nerves ;  /,  iliac  fascia  covering  iliac  vessels ;  g,  gluteal  ves- 
sels ;  h,  sciatic  vessels ;  i,  internal  pudic  vessels  ;  k,  obturator  vessels. 

From  its  insertion  on  the  pelvic  wall  the  vesico-rectal  fascia  goes 
inward  and  downward,  covering  the  upper  surface  of  the  levator  ani 
muscle,  to  the  base  of  the  bladder,  the  vagina,  and  the  rectum.  In 
front,  near  the  middle  line,  a  thicker,  narrow  part  of  this  fascia  forms 
the  anterior  true  ligaments  of  the  bladder,  or  the  pubo-vesical  ligaments 
(see  p.  80). 

Between  the  two  ligaments  the  fascia  is  thin  and  depressed.  Out- 
side of  this  ligament  lies  another,  thicker  band,  the  lateral  true  liga- 
ment of  the  bladder,  which  is  attached  to  the  side  of  the  bladder. 


96  DISEASES  OF  WOMEN. 

From  the  under  surface  of  the  vesico-rectal  fascia  a  prolongation  fol- 
lows down  with  the  vagina,  surrounding  it  with  a  sheath  that  lies 
outside  of  the  venous  plexus  and  forms  a  strong  ring  around  the 
vaginal  entrance,  where  it  coalesces  with  the  deep  perineal  fascia. 

From  the  ischial  spine  goes  a  band  to  the  side  of  the  rectum,  which 
is  called  the  ligament  of  the  rectum,  and  prevents  too  great  lateral 
movement  of  the  intestine.  The  fascia  follows  the  rectum  down  as 
a  sheath  which  gradually  disappears  near  the  anus.  From  the  place 

FIG.  94. 


The  Levator  Ani :  appearance  when  the  pelvic  outlet  is  looked  at  squarely.    The  cut  ends 
projecting  inward  are  those  fibres  which  run  into  the  recto-vaginal  septum  (Dickinson). 

where  it  strikes  the  rectum  it  is  continued  over  on  the  pyriformis 
muscle  as  the  pyriformis  fascia. 

In  some  parts  a  double  layer  of  fascia,  with  intervening  loose  con- 
nective tissue,  serves  to  allow  a  sliding  movement  of  one  part  on  the 
other.  Thus  the  fascia  forms  a  pouch  between  the  base  of  the  blad- 
der and  the  neck  of  the  womb,  extending  an  inch  lower  down  than 
the  corresponding  vesico-uterine  pouch  of  the  peritoneum.  Between 
the  vagina  and  the  rectum  a  similar  pouch  is  found  which  descends 
nearly  to  the  vaginal  entrance. 

In  its  totality  the  pelvic  fascia  forms  a  very  irregular  fibrous  layer 
under  the  peritoneal  cavity  and  the  underlying  loose  connective  tissue, 
the  function  of  which  is  to  strengthen  the  pelvic  floor  and  give  sup- 
port to  the  organs  found  in  it,  especially  the  bladder,  the  vagina,  and 
the  rectum. 


ANATOMY.  97 

II.  The  Pelvic  Diaphragm  (Fig.  94). — Under  the  pelvic  fascia, 
which  forms  a  fibrous  layer  of  the  pelvic  floor,  is  found  a  horseshoe- 
shaped  muscular  expansion,  which  is  open  in  front,  is  attached  all 
around  to  the  wall  of  the  pelvis,  and  forms  a  double  loop  behind  the 
vagina  and  the  rectum.  It  is  generally  described  as  two  muscles,  the 
levator  ani  and  the  coccygeus,  but  they  touch  each  other  with  their 
edges,  so  that  one  is  a  continuation  of  the  other,  and  sometimes 
they  are  even  grown  together.  This  diaphragm  has  also  been  de- 
scribed as  composed  of  three  muscles :  the  pubo-coceygeus,  the  obturato- 
coccygeus,  and  the  ischio-coccygeus  (Savage),  but  not  one  of  the  fibers 
that  start  from  the  pubes  are  inserted  on  the  coccyx. 

The  levator  ani  muscle  takes  its  origin  from  an  oblique  line  on  the 
posterior  surface  of  the  body  of  the  pubic  bone,  running  from  the 
upper  end  of  the  obturator  foramen  to  the  lower  end  of  the  symphysis 
pubis,  just  above  and  inside  of  the  insertion  of  the  obturator  internus 
muscle  (M.  pubo-coceygeus).  It  starts  half  an  inch  from  the  middle 
line  of  the  symphysis.  Its  other  bony  origin  is  a  small  circle  just 
in  front  of  the  base  of  the  ischial  spine.  Between  these  two  points 
it  springs  from  the  tendinous  arch  of  the  pelvic  fascia  (M.  obturato- 
coccygeus). 

The  pubic  portion  (M.  pubo-coceygeus)  goes  backward  and  inward, 
is  in  connection  with  the  deep  layer  of  the  triangular  ligament,  and  is 
attached  to  the  urethra.  It  crosses  the  vagina,  and  is  united  to  it  by 
strong  connective-tissue  attachments,  besides  that  the  longitudinal 
fibers  of  the  vagina  on  its  lateral  aspects  are  interwoven  with  those 
of  the  levator.  Some  loops  go  from  side  to  side  between  the  vagina 
and  the  rectum,  but  the  greater  part  go  behind  the  rectum,  forming 
loops  without  intermediate  tendon.  They  hug  the  concavity  of  the 
end-curve  of  the  rectum  and  support  it  from  below  (Fig.  95).  The 
muscle  goes  in  between  the  external  and  internal  sphincter,  and  in- 
termingles with  both  of  them,  as  well  as  with  the  longitudinal 
fibers  of  the  rectum.  Some  of  the  fibers  are  inserted  on  the  thin 
mesial  aponeurosis,  extending  from  the  coccyx  to  the  anus  (raphe 
ano-coccygea). 

The  fascial  portion  of  the  levator  ani  muscle  (M.  obturato-coc- 
cygeus)  goes  with  convergent  fibers  to  the  rectum  and  the  coccyx. 
It  takes  part  with  the  pubic  portion  in  the  formation  of  a  loop  behind 
the  rectum,  and  another  part  of  it  is  inserted 'on  the  fourth  coccygeal 
vertebra. 

The  ischio-coccygeal  muscle  (=  the  coccygeus)  forms  likewise  a  tri- 
angle, but  the  base  of  this  triangle  is  turned  inward.  It  takes  its 
origin  on  the  spine  of  the  ischium  and  the  lesser  sacro-sciatic  liga- 
ment, and  is  inserted  on  the  side  of  the  upper  part  of  the  coccyx  and 
the  last  two  vertebrae  of  the  sacrum. 

Function. — The  pelvic  diaphragm  strengthens  the  pelvic  floor;  in 
7 


98 


DISEASES  OF  WOMEN. 


connection  with  the  two  fasciae  that  cover  its  upper  and  lower  surface 
(the  vesico-rectal  and  the  anal  fasciae)  it  forms  a  strong  sheet  on 
which  rest  the  uterus  and  the  bladder.  It  is  the  antagonist  of  the 
thoracic  diaphragm,  being  relaxed  under  inspiration  and  contracting 
under  expiration.  By  inserting  a  Sims  speculum  it  is  easy  to  see 


FIG.  95. 


Anus 


Side  View  of  the  Levator  Ani  (L)  after  Removal  of  the  Ischium.  The  lower  bundles  are  the 
strong  and  heavy  ones.  The  sphincter  ani  is  shown  surrounding  the  anus,  and  the 
coccygeus  (C)  is  faintly  indicated  (Luschka-Dickinson) : 

the  rhythmical  movement  synchronous  with  the  respiration.     The 
anterior  wall  of  the  vagina  goes  downward  and  backward  under 
inspiration,  and  then  upward  and  forward  during  exspiration. 
The  pelvic  diaphragm  lifts  the  rectum  up  during  the  act  of  defeca- 


ANATOMY. 


99 


tion,  and  draws  the  auus  forward  in  the  direction  of  the  symphysis. 
It  exercises  a  similar  function  toward  the  vagina  during  childbirth 
bv  pulling  it  upward  and  pushing  the  child  forward,  so  as  to  make 
it  turn  round  the  pubic  arch.  By  means  of  the  loops  that  go  between 
the  vagina  and  the  rectum  it  becomes  a  sphincter  vagina?,  which  can 
produce  coarctation  of  the  vaginal  entrance.  It  draws  the  coccyx 
forward. 

III.  The  Perineal  Region. — The  perineal  region  is  a  somewhat 
rhomboid  space  bounded  by  the  symphysis  and  the  descending  ramus 
of  the  pubic  bone,  the  ascending  ramus  and  the  tuberosity  of  the 
ischium,  the  lower  edge  of  the  glutens  maximus  muscle,  and  the  tip 
of  the  coccyx.  In  depth  it  comprises  all  the  tissue  lying  within  these 
boundary-lines  between  the  surface  and  the  pelvic  diaphragm.  It  is 
shorter  and  broader  than  in  man,  and  contains  more  fat.  It  may  be 
subdivided  by  a  line  drawn  just  in  front  of  the  tuberosity  of  the 

Fro.  96. 


Diagram  of  the  Fascia  of  the  Pelvic  Floor  in  mesial  section,  to  show  how  the  levator  ani 
muscle  is  backed  by  strong  and  dense  sheets  of  fibrous  tissue  (Dickinson) :  1,  superficial 
perineal  fascia,  outer  layer  (this  we  call  simplv  subcutaneous  adipose  tissue^ :  2.  super- 
ficial perineal  fascia,  inner  layer  (our  superficial  perineal  fascia):  3,  triangular  ligament, 
or  deep  perineal  fascia,  outer  layer:  4,  triangular  ligament,  or  deep  perineal  fascia,  inner 
layer;  5,  vesico-rectal  (part  of  pelvic)  fascia. 

ischium  on  either  side  into  two  triangles,  an  anterior,  or  uro-genital 
region,  and  a  posterior,  or  anal  region. 


100 


DISEASES  OF  WOMEN. 


FIG.  97. 


In  the  anterior  triangle  we  distinguish  the  following  layers : 

Skin; 

Adipose  tissue ; 

Superficial  perineal  fascia; 

Deep  perineal  fascia  divided  into  two  layers; 

Anterior  continuation  of  ischio-rectal  fossa  ; 

Levator  ani  muscle ; 

Vesico-rectal  fascia  (i.  e.  part  of  pelvic  fascia). 
In  the  posterior  triangle  are  found  the  following  layers : 

Skin; 

Adipose  tissue  entering  and  filling  ischio-rectal  fossa ; 

Anal  fascia  inside,  lower  part  of  obturator  fascia  outside ; 

Levator  ani  muscle  inside,  obturator  muscle  outside ; 

Vesico-rectal  fascia. 

A.  The  Perineal  Fascia  and  Ligaments. — The  uro-genital  region 
has  under  the  skin  a  layer  of  adipose  tissue  (Fig.  96),  which  is  a 
continuation  of  the  similar  layer  on  the  surrounding  parts  (Fig.  97). 

Under  that  layer  is  found  a  sheet 
of  dense  connective  tissue  called 
the  superficial  perineal  fascia.  It 
is  fastened  in  front  and  on  the 
sides  to  the  edge  of  the  rami  of  the 
pubis  and  ischium,  and  behind  it 
turns  over  the  superficial  trans- 
versus  perinsei  muscle,  and  is  here 
grown  together  with  the  deep  peri- 
neal fascia.  In  its  anterior  part  it 
is  grown  'together  with  Broca's 
pouch  (p.  37),  and  at  the  ramus 
of  the  ischium  with  the  obturator 
fascia. 

The  deep  perineal  fascia,  also 
called  the  triangular  ligament  of 
the  urethra,  has  two  layers — an 
anterior,  or  superficial  layer,  and  a 
posterior,  or  deep  layer.  The  su- 
perficial layer  is  at  the  sides  at- 
tached to  the  rami  of  the  pubes 
and  ischium,  in  front  to  a  strong 
transverse  ligament  called  the 
transverse  ligament  of  the  pelvis 
(Henle),  which  lies  immediately 
under  and  behind  the'  subpubic 
ligament,  an  opening  for  the  dorsal 
vein  of  the  clitoris  separating  the  two.  Behind  it  is  grown  together 


2PM4 

Transverse  Section  of  Pelvis  through  Axis 
of  Vagina  (Savage) :  V,  vagina,  snowing 
posterior  wall;  O,  ischio-rectal  fossa  filled 
with  fat;  I,  ischial  tuberosity ;  B,  perito- 
neal cavity;  D,  recto- vesical  fascia  cover- 
ing upper  surface  of  levator  ani  muscle  ; 
C,  anal  fascia  covering  lower  surface  of 
levator  ani;  N,  obturator  fascia;  P,  pos- 
terior aponenrosis  of  perineal  septum,  or- 
the  deep  layer  of  the  triangular  ligament ; 
M,  anterior  aponeurosis  of  the  same,  or 
superficial  layer  of  the  triangular  liga- 
ment; S,  superficial  perineal  fascia;  1, 
cross-section  of  right  crus  clitoridis  and 
erector  clitoridis  muscle ;  2,  superficial 
transversus  perinaei  muscle ;  3,  bulb ;  4, 
deep  perineal  muscles. 


ANATOMY.  101 

with  the  superficial  perineal  fascia  and  with  the  deep  layer  of  the 
deep  fascia.  The  deep  layer  of  the  deep  fascia  is  likewise  fastened  to 
the  rami  of  the  pubes  and  the  ischium,  where  it  joins  the  obturator 
fascia  (p.  94),  and  covers  the  anterior  part  of  the  lower  surface  of 
the  levator  ani  muscle.  At  its  anterior  attachment  it  is  contiguous 
with  the  vesico-rectal  fascia.  Behind  it  is  continued  as  a  dense  fascial 
sheet  covering  the  lower  surface  of  the  levator  ani  muscle  (the  anal 
fascia,  or  levator  fascia). 

The  deep  perineal  fascia  is  perforated  by  the  urethra  and  the  vagina. 

Where  the  superficial  perineal  fascia  and  the  two  layers  of  the  deep 
periueal  fascia  come  together,  at  the  posterior  margin  of  the  super- 
ficial transversus  perinsei  muscle,  they  are  fortified  by  a  strong  trans- 
verse fibrous  band,  the  ischio-perineal  ligament,  which  is  inserted  on 
the  ramus  of  the  ischium,  just  in  front  of  the  tuberosity,  and  forms  the 
boundary-line  between  the  uro-genital  and  the  anal  regions.  It  is  a 
strong  cross-beam,  which  by  its  connection  with  all  the  adjacent  parts 
forms  the  chief  support  of  the  pelvic  floor.  Together  with  the  pos- 
terior end  of  the  superficial  and  deep  perineal  fasciae  it  forms  a  parti- 
tion between  the  anterior  and  posterior  part  of  the  perineal  region, 
called  the  transverse  perineal  septum. 

In  the  anal  region  the  skin  is  darker  and  has  large  sebaceous  glands. 
The  anus  forms  an  opening  at  the  deepest  point  of  the  sulcus  between 
the  nates.  It  is  closed  from  side  to  side  so  as  to  show  a  line  of  closure 
in  the  antero-posterior  direction  (Fig.  87,  12).  It  is  surrounded  by 
radiating  folds  of  the  skin,  and  often  hairs.  In  women  the  raphe 
between  the  anus  and  the  vulva  (perineal  raphe)  is  often  effaced,  and 
has  sometimes  a  whitish  color,  much  like  a  cicatrix,  which  has  to  be 
borne  in  mind  in  answering  the  question  whether  a  subject  for 
examination  has  given  birth  to  a  child  or  not.  Under  the  skin  is 
found  a  thick  layer  of  adipose  tissue.  There  is  no  special  superficial 
fascia,  and  the  deep  perineal  fascia  does  not  extend  so  far  back. 

Between  the  rectum  and  the  ischium  is  found  a  space  on  either 
side  which  is  called  the  ischlo-rectal  fossa,  and  has  the  shape  of  an 
irregular  triangular  pyramid.  Its  top  is  at  the  spine  of  the  ischium  ; 
the  inner  wall  is  formed  by  the  levator  aui  muscle,  covered  by  the 
anal  fascia,  the  outer  by  the  obturator  internus  muscle,  covered  by 
the  obturator  fascia,  below  the  line  of  demarkation  between  that  fascia 
and  the  vesico-rectal  fascia  covering  the  upper  surface  of  the  levator 
ani  muscle  (p.  94).  Its  entrance  from  below  is  bounded  by  the 
lower  edge  of  the  gluteus  maximus  and  the  greater  sacro-sciatic  liga- 
ment behind,  the  transversus  perinaei  superficialis  muscle  in  front,  and 
the  external  sphincter  ani  on  the  inner  side.  Posteriorly  these  two 
spaces  communicate  by  means  of  the  loose  adipose  tissue  behind  the 
rectum  and  pelvic  fascia.  In  front  the  fossa  is  limited  by  the  line 
of  junction  of  the  superficial  and  deep  perineal  fascise.  Here  it  be- 


102  DISEASES  OF  WOMEN. 

conies  narrow,  but  may  be  followed  above  the  deep  fascia  of  the 
perineum  along  the  origin  of  the  levator  ani  muscle.  It  appears 
triangular  both  on  perpendicular  and  horizontal  section  (Figs.  92 
and  97). 

The  above-mentioned  fasciae  constitute  a  frame-work  in  which  lie 
imbedded  muscles,  blood-vessels,  nerves,  and  other  organs. 

B.  Perineal  Muscles. — In  the  uro-genital  triangle  we  find  a  super- 
ficial layer  of  three  pairs  of  muscles  (Fig.  87,  p.  86)  situated  between  the 


Perineal  Muscles  (Henle) :  CL,  clitoris  turned  over  to  the  left  side  ;  CCC,  corpus  cavernosum 
clitoridis;  CCU,  corpus  cavernosum  urethrse,  or  vestibulo-vaginal  bulb;  CVA,  anterior 
column  of  vagina ;  CW,  vulvo-vaginal  gland ;  BC,  1, 2, 3,  bulbq-cavernosus  muscle ;  JC,  1, 2, 
ischio-cavernosus  muscle ;  TPS,  transversus  perinsei  superficialis ;  TPP,  transversus  peri- 
nsei  profundus  muscle;  S,  1,  2  ,3,  sphincter  ani  externus;  XX,  layer  of  smooth  muscle- 
fibers  between  vagina  and  rectum ;  +,  limit  of  pubes  and  ischium. 

superficial  perineal  fascia  and  the  anterior  layer  of  the  deep  perineal 
fascia — namely,  the  ischio-cavernosus,  or  erector  clitoridis  muscle;  the 
bulbo-cavernosus,  or  sphincter  vaginae,  muscle;  and  the  superficial 
transversus  perincei  muscle. 

The  ischio-cavernosus  muscle  is  a  long,  slender  muscle  which  arises 
by  two  slips  on  the  inside  of  the  tuberosity  of  the  ischium  and  the 
ascending  ramtis  of  the  same  (Fig.  98).  It  covers  the  corpus  cav- 
ernosum of  the  clitoris,  and  is  inserted  with  a  tendinous  expansion 
on  the  free  part  of  the  clitoris.  Its  function  in  the  female  is  insig- 
nificant compared  with  that  in  the  other  sex. 

The  bulbo-cavernosus  muscle  receives  some  fibers  from  the  external 
sphincter  ani  and  levator  ani  and  the  superficial  transversus  perinsei 

'/' 


ANATOMY.  103 

muscles,  and  others  originate  on  the  ischio-perineal  ligament  and 
neighboring  tendinous  tissue.  The  posterior  ends  are  united  by 
organic  muscular  libers.  It  goes  forward,  outside  of  the  vulvo-vagi- 
nal  bulb,  and  splits  tip  into  three  tendons,  inserted  one  on  the  poste- 
rior aspect  of  the  bulb,  another  on  the  mucous  membrane  between 
the  clitoris  and  the  urethra,  and  the  third  on  the  lower  surface  of  the 
clitoris.  It  compresses  the  bulb,  and  thus  aids  in  the  erection  of  the 
clitoris.  It  may  squeeze  out  the  secretion  accumulated  in  Bartholin's 
gland.  The  role  of  sphincter  it  divides  with  the  constrictor  vagina?, 
and,  above  all,  the  levator  ani  muscle. 

The  superficial  transversus  perincei  muscle  originates  from  the  inside 
of  the  tuberosity  of  the  ischium,  behind  the  ischio-cavernosus  muscle, 
goes  across  the  perineal  region,  and  is  inserted  in  the  transverse  sep- 
tum of  the  perineum  in  the  angle  between  the  bulbo-cavernosus  and 
the  sphincter  ani  externus,  intermingling  with  both.  In  many  women 
its  course  is  more  forward,  so  that  it  does  not  reach  the  perineal  body, 
but  is  fastened  to  the  outer  edge  of  the  bulbo-cavernosus  muscle. 
When  it  has  its  normal  insertion  it  helps  to  steady  the  perineal  body 
and  push  the  presenting  part  of  the  child  forward  toward  the  pubic 
arch  during  parturition.  With  its  abnormal  insertion  it  can  only 
help  to  open  the  vaginal  entrance. 

In  the  anal  region  we  find  immediately  under  the  skin  surround- 
ing the  anus  the  external  sphincter  ani  muscle  (p.  87). 

Under  the  tendon  of  the  sphincter  ani  muscle,  between  it  and  the 
levator  ani  muscle,  in  front  of  the  tip  of  the  coccyx,  lies  the  so-called 
Goccygeal  gland,  a  small  body  of  the  size  of  a  pea,  which  seems  to  be 
a  remnant  of  a  more  developed  middle  sacral  artery,  such  as  it  is 
in  animals  with  a  tail.1  It  consists  of  round  or  tubuliform  vesicles 
formed  by  a  structureless  membrane,  inside  of  which  are  found  cells. 
The  whole  is  surrounded  by  a  capsule  of  connective  tissue,  and  re- 
ceives numerous  branches  from  the  middle  sacral  artery  and  the  sym- 
pathetic nerve,  especially  the  coccygeal  ganglion. 

The  deep  muscles  in  the  uro-geuital  region  are  not  well  develojred 
or  clearly  separated  from  one  another.  They  are,  therefore,  enu- 
merated and  described  differently  by  different  anatomists.  Most 
commonly  the  following  three  are  recognized  :  the  constrictor  urethrce, 
the  deep  transversus  perincei,  and  the  constrictor  vagince  muscles.2 
They  are  all  situated  between  the  two  layers  of  the  deep  perineal 
fascia. 

The  constrictor  urelhrce,  or  compressor  urethrce,  or  Guthriffs  muscle, 

1  An  interesting  article  on  this  subject,  illustrated  with  figures,  was  published  by 
Augustus  C.  Bernays  of  St.  Louis  in  the  Medical  Brief,  Nov.,  1887,  vol.  xv.  p.  419. 

2  Some  describe  a  depressor  urelhrce  (or  Jarjavay's  muscle),  a  transverse  muscle  join- 
ing the  constrictor  from  below  and  going  from  side  to  side  over  the  urethra,  and  a 
transversus  urethrce  muscle,  coming  from  above  and  inserted  on  the  upper  surface  of 
the  same.     They  are  probably  only  parts  of  the  constrictor  urethrce. 


104  DISEASES  OF  WOMEN. 

consists  of  transverse  fibers  arising  from  the  ischio-pubic  rami  and 
both  layers  of  the  deep  perineal  fascia,  and  crossing  from  side  to  side 
above  and  below  the  urethra,  for  which  thev  form  an  upper  sphincter 
(P.  76). 

The  deep  transversus  perincei  muscle  arises  from  the  ramus  of  the 
ischium  just  behind  the  constrictor  urethras,  and  goes  horizontally  to 
the  side  of  the  vagina.  By  some  it  is  merely  regarded  as  the  poste- 
rior fibers  of  the  constrictor.  It  helps  to  steady  the  vagina. 

The  constrictor  vaginae  muscle  consists  of  a  few  fibers  which  arise 
from  the  transverse  septum  of  the  perineum,  and  encircle  the  vaginal 
entrance  as  a  sphincter.  Thus  the  deep  transversus  and  the  con- 
strictor vaginae  correspond  to  the  superficial  transversus  and  the 
bulbo-caveruosus  of  the  superficial  layer. 

In  the  anal  region  we  have  the  internal  sphincter'  ani  (p.  87)  and 
the  levator  ani,  inclusive  of  the  ischio-coccygeus  (p.  97).  The  ante- 
rior part  of  the  levator  ani  lies  immediately  on  the  deep  layer  of  the 
deep  perineal  fascia. 

C.  The  Perineal  Body. — The  name  of  perineal  body  has  been  given 
to  the  tissue  comprised  between  the  rectum  and  the  genital  canal, 
below  the  point  where  the  former  turns  backward  (p.  84).  Much 
diversity  obtains  among  authors  about  its  shape — a  divergence  of 
opinion  easily  accounted  for  when  \ve  notice  how  different  its  shape 
appears  on  sagittal  section  (Figs.  34,  49,  89).  Sometimes  the  whole 
space  between  the  rectum  and  the  vagina  up  to  the  cervix  uteri  forms 
one  triangular  surface.  In  other  cases  this  space  is  easily  distinguish- 
able into  an  upper  narrow  and  a  lower  broad  part,  the  latter  alone 
deserving  the  name  of  perineal  body ;  but  this  body,  again,  appears 
with  very  different  forms,  and  differs  in  extension  upward.  Some- 
times the  whole  body  lies  below  the  hymen ;  in  other  cases  it  extends 
more  or  less  up  behind  the  vagina.  The  shape  is  sometimes  nearly 
quadrangular,  with  one  surface  to  the  skin,  one  to  the  rectum,  one  to 
the  vulva,  and  one  to  the  vagina.  In  others  it  has  the  shape  of  the 
quadrant  of  a  circle;  in  others,  again,  that  of  the  receiver  of  a  retort, 
the  neck  of  which  is  formed  by  the  narrow  part  between  the  vagina 
and  the  rectum.  When  we  take  into  consideration  that  all  the  parts 
concerned  consist  of  more  or  less  soft  tissue,  this  great  diversity  of 
form  is  easily  understood. 

The  perineal  body  (Fig.  99)  is  composed  of  the  posterior  ends  of 
the  bulbo-cavernosi  muscles,  the  organic  muscular  fibers  uniting  them 
behind,  fibers  belonging  to  the  superficial  transversus  perinaei,  the 
external  and  internal  sphincter  ani,  and  the  levator  ani  muscles,  the 
ischio-perineal  ligament,  the  posterior  part  of  the  superficial  and  deep 
perineal  fasciae,  the  anal  fascia,  and  adipose  tissue.  It  is  covered 
below  by  the  skin  lying  between  the  anus  and  the  rima  pudendi ; 
behind  by  the  rectal  mucous  membrane ;  above  and  in  front  by  the 


ANATOMY.  105 

mucous  membrane  of  the  vulva  and  sometimes  of  tne  vagina.     It 
has  no  definite  lateral  limits,  unless  we  arbitrarily  suppose  it  con- 


FIG.  99. 


fianoular  iyaitf 
Juperticialjayer. 

Sup-Perintal  fofria. 


Sagittal  Section  of  the  Perineal  Body,  showing  its  component  structures  (life  size ; 

Dickinson]. 

tinued  to  the  tuberosity  of  the  ischium.  The  cutaneous  surface  is 
shorter  than  in  man.  It  measures  |  to  1  inch  in  length,  while  the 
distance  from  the  anus  to  the  entrance  of  the  vagina  (p.  43),  the 
true  length  of  the  perineal  body,  is  about  If  inches.  According  to 
what  has  just  been  said  about  its  upper  limit,  no  definite  height  can 
be  ascribed  to  it. 

Small  as  this  body  is,  it  is  of  great  importance  by  forming  the  cen- 
tre of  the  whole  perineal  region,  where  muscles,  fasciae,  and  ligaments 
come  together.  They  being  fastened  to  the  surrounding  bones,  the 
perineal  body  becomes  the  chief  support  of  the  whole  pelvic  floor. 
Especially  it  keeps  the  vagina  and  the  rectum  in  their  proper  relative 
position.  During  childbirth  it  forms  a  strong  barrier  against  which 
the  child  is  being  pressed  from  above  and  pushed  by  passive  and 
active  counter-pressure  forward  around  the  pubic  arch. 

D.  The  Projection  of  the  Pelvic.  Floor. — The  perineal  region  forms 
a  curve  in  the  antero-posterior  direction.     The  most  projecting  por- 
tion  is  that  immediately  surrounding  the  anus.     The  average  dis- 
tance from  this  point  to  a  straight  line  drawn  from  the  tip  of  the 
coccyx  to  the  top  of  the  pubic  arch  (i.  e.  the  diagonal  diameter  of  the 
outlet  of  the  pelvis)  is  1  inch.1 

E.  The  Arteries  of  the  Perineal  Region  are  the  internal  pudic  and 
branches  thereof,  and  the  superficial  and  deep  external  pudic.     The 
internal  pudic  artery,  a  branch  of  the  internal  iliac,  is  much  smaller 
than  in  the  male.     It  passes  downward  and  outward,  emerges  from 
the  pelvis  through  the  greater  ischiadic  foramen,  between  the  pyri- 

1  Foster,  Amer.  Jour.  Obstei.,  1880,  vol.  xiii.  pp.  35,  36. 


106 


DISEASES  OF  WOMEN. 


formis  and  ischio-coccygeus  muscles,  goes  behind  the  spine  of  the 
ischium,  re-enters  the  pelvis  through  the  lesser  ischiadic  foramen,  goes 
inside  of  the  ischium,  1|  inches  above  the  lower  end  of  the  tuberosity, 
where  it  lies  on  the  obturator  interims  muscle  in  a  sheath  formed  by 
the  obturator  fascia  and  the  falciform  ligament,  a  prolongation  of  the 
greater  sacro-sciatic  ligament.  It  reaches  the  margin  of  the  ascending 
branch  of  the  ischium,  perforates  the  deep  layer  of  the  deep  perineal 
fascia,  continues  its  course  along  the  margin  of  the  descending  branch 
of  the  pubis,  perforates  the  superficial  layer  of  the  same  fascia,  and 
finally  divides  into  its  two  end-branches,  the  dorsal  artery  of  the 
clitoris  and  the  artery  of  the  corpus  cavernosum.  Before  that  it  gives 
oif  four  branches  to  the  perineum — the  inferior  hemorrhoidal,  the 
superficial  perineal,  the  transverse  perineal)  and  the  artery  of  the 
bulb  (Figs.  100  and  101). 

FTG.  100. 


Superficial  Structures  of  the  Female  Perineum  (Weisse):  a,  external  superficial  perineal 
nerve ;  6,  internal  superficial  perineal  nerve :  c,  superficial  perineal  artery  {  d,  inferior 
pudendal  nerve ;  e,  pudic  nerve ;  /,  internal  pudic  artery ;  g,  inferior  hemorrhoidal 
artery ;  h,  inferior  hemorrhoidal  nerve ;  i,  tendinous  center  of  perineum ;  j,  coccyx. 

The  inferior  hemorrhoidal  consists  of  two  or  three  branches  which 
start  on  the  inside  of  the  tuberosity,  cross  the  ischio-rectal  fossa,  and 


Ay  ATOMY. 


107 


end  between  the  skin  and  external  sphincter  aui,  giving  branches  to 
them  and  the  levator  ani. 

FIG.  101. 


Dissection  of  Female  Perineum ;  on  the  left  side  the  perineal  muscles  are  exposed  by  the 
reflection  of  the  perineal  fascia ;  on  the  right  side  the  muscles  and  the  superficial  layer 
of  the  triangular  ligament  have  been  removed,  thereby  exposing  the  deep  layer  of  the 
ligament  (modified  from  Weisse) :  a,  dorsal  vein  of  clitoris;  b,  dorsal  artery  of  clitoris; 
c,  inferior  pudendal  nerve;  d,  artery  of  bulb;  e,  pudic  nerve;  /,  internal  pudic  artery : 
g,  inferior  hemorrhoidal  artery;  h,  inferior  hemorrhoidal  nerve;  i,  tendinous  perineal 
center;  ;',  superficial  transversus  perinaei  muscle. 

The  superficial  perineal  artery  is  a  longer  branch.  It  originates  a 
little  in  front  of  the  former,  runs  parallel  to  the  ischio-pubic  branches, 
either  above  or  below  the  transversus  perinsei  muscle,  between  the 
superficial  and  the  deep  perineal  fascia,  and  between  the  ischio-cav- 
ernosus  and  bulbo-cavernosus  muscles.  It  then  passes  through  the 
superficial  perineal  fascia,  in  which  respect  it  differs  from  the  corre- 
sponding artery  in  the  male.  It  sends  branches  to  the  named  muscles 
and  ends  in  the  vulva. 

The  transverse  perineal  artery  perforates  the  deep  layer  of  the  deep 
perineal  fascia,  follows  the  superficial  transverse  perineal  muscle,  and 
supplies  this  muscle,  the  vestibule-vaginal  bulb,  and  Bartholin's  gland. 

The  artery  of  the  bulb  is  smaller  than  in  the  opposite  sex.     It  comes 


108  DISEASES  OF   WOMEN. 

from  the  internal  pudic  between  the  two  layers  of  the  deep  perineal 
fascia,  and  pierces  the  superficial  layer  of  the  same.  It  supplies  the 
vestibulo-vaginal  bulb  and  the  meatus  urinarius. 

The  artery  of  the  corpus  cavernosum  and  the  dorsal  artery  of  the 
clitoris  are  much  smaller  than  in  the  male,  and  that  of  the  corpus  cav- 
ernosum is  again  the  smaller  of  the  two,  while  in  the  other  sex  the 
opposite  is  the  case.  The  artery  of  the  corpus  cavernosum  is  dis- 
tributed in  the  crus.  The  dorsal  artery  of  the  clitoris  follows  the 
upper  surface  of  the  clitoris,  and  ends  in  the  glans  and  prepuce. 

The  superficial  external  pudic  artery  is  a  branch  of  the  femoral, 
passes  through  the  saphenous  opening,  and  spreads  on  the  labia 
majora. 

The  deep  external  pudic  artery  comes  likewise  from  the  femoral. 
It  crosses  the  pectineus  muscle,  pierces  the  fascia  lata  at  the  inner 
side  of  the  thigh,  and  goes  to  the  labia  majora,  where  it  anastomoses 
with  the  superficial  perineal  artery. 

Hemorrhage. — In  the  median  line  of  the  perineal  region  there  is 
no  artery  of  any  importance.  The  nearer  an  incision  is  made  to  the 
tuberosity  of  the  ischium  and  the  ischio-pubic  branches,  the  greater 
is  the  danger  of  hemorrhage.  The  internal  pudic  artery  is  the  only 
one  that  requires  ligature  on  both  ends  (Ranney). 

F.  The  Veins  of  the  Perineal  Region  lead  to  the  internal  pudic  and 
the  internal  saphenous  veins.     From  the  hemorrhoidal  plexus  (p.  89) 
the  inferior  hemorrhoidal  vein  follows  the  homonymous  artery  to  the 
internal  pudic  vein.     In  the  uro-genital  region  the  veins  do  not  cor- 
respond with  the  arteries.     There  is  a  single  dorsal  vein  of  the  clit- 
oris, beginning  with  small  twigs  from  the  glans  and  prepuce,  running 
backward  in  the  median  line  between  the  two  dorsal  arteries.     It 
goes  through  an  opening  between  the  infrapubic  ligament  and  the 
transverse  ligament  of  the  pelvis   (p.   100),  and  divides  into  two 
branches  that  open  into  the  pudic  plexus,  which  surrounds  the  upper 
part  of  the  urethra.     To  this  plexus  go  likewise  the  veins  of  the 
corpus  cavernosum — i.  e.  several  short,  thick  trunks  which  originate 
in  the  interior  of  the  corpus  cavernosum  and  form  one  branch  on 
either  side — and  several  veins  of  the  bulb.     The  pudic  plexus  anasto- 
moses with  the  vesical  and  vaginal  plexuses  (pp.  80  and  45)  and  the 
obturator  vein.      From  this  plexus  two  internal  pudic  veins  on  either 
side  follow  the  corresponding  artery  through  the  sheath  of  the  obtu- 
rator fascia  and  open  into  the  internal  iliac  vein. 

The  external  pudic  veins  follow  the  corresponding  arteries,  and 
open  into  the  internal  saphenous  vein. 

G.  The  lymphatics  of  the  perineal  region  lead  to  the  inguinal  glands. 

H.  The  Nerves  of  the  Perineal  Region. — The  perineal.  region  re- 
ceives its  nerve-supply  from  the  pudic  nerve  and  from  the  inferior 
pudendal  branch  of  the  small  sciatic  nerve. 


AX  ATOMY.  109 

The  pudic  nerve  comes  from  the  sacral  plexus,  follows  the  internal 
pudic  artery  out  through  the  great  sacro-sciatic  foramen,  behind  the 
spine  of  the  ischium,  and  in  through  the  lesser  sacro-sciatic  foramen. 
Its  branches  are  the  inferior  hemorrhoidal,  the  perineal,  and  the  dorsal 
nerve  of  the  clitoris. 

The  inferior  hemorrhoidal  nerve  crosses  the  ischio-rectal  fossa,  lies 
between  the  skin  and  the  superficial  perineal  fascia,  and  gives  branches 
to  the  external  sphincter  ani  and  the  skin  around  the  anus.  Its  ante- 
rior branches  combine  with  those  of  the  superficial  periueal  and  inferior 
pudendal  nerves. 

The  perineal  nerve  is  the  chief  branch.  It  lies  inside  of 
the  ischium,  below  the  internal  pudic  vessels,  in  the  same  sheath 
of  the  obturator  fascia.  It  breaks  up  into  superficial  and  deep 
branches. 

The  superficial  perineal  nerves  are  two  in  number — an  external  or 
posterior  and  an  internal  or  anterior.  They  run  forward  between  the 
superficial  and  the  deep  perineal  fascia,  perforate  the  superficial  fascia 
so  as  to  come  to  lie  between  it  and  the  skin,  one  on  either  side  of  the 
superficial  perineal  artery,  and  end  in  the  labia  majora.  They  give 
branches  to  the  skin,  and  connect  with  branches  from  the  inferior 
hemorrhoidal  and  the  inferior  pudendal  nerves. 

The  deep  perineal  nerves  generally  arise  by  a  single  trunk,  and  are 
distributed  to  nearly  all  the  muscles  of  the  perineal  region — the 
sphincter  ani  externus,  levator  ani,  transversus,  bulbo-cavernosus,  and 
ischio-cavernosus — and  to  the  vestibulo-vaginal  bulb. 

The  dorsal  nerve  of  the  clitoris  is  the  deepest  branch.  It  lies  above 
the  pudic  vessels  in  the  sheath  of  the  obturator  fascia,  then  between 
the  two  layers  of  the  deep  perineal  fascia,  perforates  the  suspensory 
ligament  of  the  clitoris,  and  is  distributed  on  the  clitoris,  where  it 
combines  with  twigs  from  the  sympathetic  and  forms  a  nervous  sheath 
(p.  39).  It  supplies  the  constrictor  urethrse  muscle  and  the  corpus 
cavernosum. 

The  inferior  pudendal  nerve  is  a  branch  of  the  small  sciatic.  It 
passes  under  the  tuberosity  of  the  ischium,  pierces  the  fascia  lata, 
runs  between  the  skin  and  the  superficial  periueal  fascia  to  the  labia 
majora,  communicating  with  the  inferior  hemorrhoidal  and  superficial 
perineal  nerves. 

I.  Distribution  of  Organs  between  the  Fasciae. — The  following  table 
may  help  to  memorize  the  distribution  of  the  muscles,  vessels,  nerves, 
etc.  of  the  perineal  region  : 

(  External  sphincter  ani  muscle ; 
j          i.  ,  i          _j          Inferior  hemorrhoidal  vessels  and  nerves ; 

i  ^  |   Superficial  perineal  artery,  veins,  and  nerves  ; 

1   External  pudic  arteries  ; 
Superficial  perineal  nerves. 


110 


DISEASES  OF   WOMEN. 


Between  the  super- 
ficial perineal  and 
the  deep  perineal 
fascia. 


Between  the  two 
layers  of  the  deep 
perineal  fascia. 


Ischio-cavernosus  ) 

Bulbo-cavernosus  >  muscles; 

Superficial  transversus  periusei   ) 

Pudendal  sac ; 
•   Yestibulo- vaginal  bulb  (in  a  particular  sheath) ; 

Artery  of  bulb ; 

Dorsal  artery  of  clitoris ; 

Artery  of  corpus  cavernosum ; 

Venous  plexuses ; 

Superficial  perineal  nerves  and  vessels. 

Constrictor  urethrse  ^| 

Deep  transversus  perinaei  >  muscles ; 

Constrictor  vaginae 

Internal  pudic  artery  with  its  branches,  trans- 
verse perineal  artery  and  artery  of  the  bulb ; 

Venous  plexuses ; 

Internal  pudic  veins ; 

Deep  perineal  nerves ; 

Dorsal  nerve  of  clitoris ; 

Volvo-vaginal   glands  (sometimes  above  the 

deep  layer). 

Between  the  deep  perineal  and  f  Levator  ani  muscle  (anterior  part) ; 
the  pelvic  fascia.  \  Vulvo-vaginal  glands  (sometimes). 

J.  The  Structural  Anatomy  of  the  Pelvic  Floor. — The  vagina  per- 
forates the  pelvic  floor  at  an  angle  of  60°  with  the  horizon.1  What 
lies  in  front  of  the  vaginal  slit  has  been  called  the  pubic  segment,  and 
what  lies  behind  it  the  sacral  segment.  The  pubic  segment  is  composed 
of  loose  tissue,  and  is  loosely  attached  to  the  symphysis  pubis.  (Com- 
pare pp.  87  and  93.)  The  sacral  segment  is  made  up  of  dense  tissue, 
and  is  firmly  bound  to  the  sacrum  and  coccyx.  During  labor  the 
pubic  segment  is  drawn  up  so  that  the  empty  bladder  lies  above  the 
symphysis,  while  the  sacral  segment  is  being  driven  down  by  the 
pressure  of  the  child. 

Another  division  of  the  pelvic  floor  is  into  the  entire  displaceable 
portion  and  the  entire  fixed  portion.  The  boundary  between  these 
two  is  a  continuous  layer  of  loose  connective  tissue,  beginning  as  the 
retro-pubic  fat  (p.  9.3),  then  forming  the  loose  tissue  on  the  inside  of 
the  obturator  internus  and  upper  portion  of  the  levator  ani,  and  finally 
between  the  vagina  and  the  rectum  (Figs.  102  and  103). 

The  entire  displaceable  portion  lies  inside  of  the  entire  fixed  portion, 
and  consists  of  the  bladder,  the  urethra,  and  the  vagina.  It  has  resting 
upon  it  the  uterus,  the  broad  ligaments,  the  tubes,  and  the  ovaries. 

1  Hart  is  the  first  who  has  explained  the  structure  of  the  pelvic  floor  in  his  re- 
markable thesis,  The  Structural  Anatomy  of  the  Pelvic  Floor  (Edinburgh,  1880). 


Ill 


Horizontal  Section  of  Pelvis  at  Plane  of  Hip-joint  (Rydygier) :    o,  coccyx ;  b,  ischio-rectal 
fossa;  c,  rectum  ;  d,  vagina;  e,  bladder;  /,  retro-pubic  fat;  g,  hip-joint. 

The  entire  fixed  portion  has  the  shape  of  a  funnel,  wide  above  and 
narrow  below.     These  two  different  divisions  may  be  contrasted 
the  following  way : 


in 


Seen  in  Sagittal  Mesial 
Sections. 


Pubic  segment. 


Sacral  segment. 


i 


Seen  in  Horizontal  Sec- 
tions. 


Entire    displace- 
able  portion. 

Entire  fixed  por- 
tion. 


Bladder  with  urethra. 
Anterior  vaginal  wall. 
Posterior  vaginal  wall. 
Tissue  attached  to  sacrum. 
(  Rectum. 
All  outside  of  inner  aspect  of 

levator  ani. 

K.  The  Function  of  the  Pelvic  Floor. — The  pelvic  floor  counteracts 
the  abdominal  pressure  from  above.  The  loose  tissue  surrounding  the 
bladder  and  the  rectum  allows  these  organs  to  be  distended  and  emp- 
tied. Its  role  during  the  act  of  copulation  has  been  referred  to  in 
describing  the  vulva  and  the  vagina,  and  the  effect  of  the  contraction 
of  the  perineal  muscles  and  the  levator  ani  in  narrowing  the  genital 
canal  is  easily  understood. 

During  parturition  the  entire  displaceable  portion  is  being  pulled 
upward  by  the  contractions  of  the  muscular  fibers  of  the  uterus,  which 
are  continued  on  the  vagina  (p.  49).  The  child  is  pushed  through 
the  vagina,  exerting  a  strong  pressure  on  its  posterior  wall,  on  account 
of  the  angle  between  the  uterus  and  the  vagina.  The  active  and 


112 


DISEASES  OF  WOMEN. 
FIG.  103. 


Coronal  Section  of  Frozen  Body  (Rydygier) :  1,  right  lung;  2,  right  atrium  with  fovea  ovalis; 
3,  left  atrium;  4,  right  branch  of  pulmonary  artery;  5,  arch  of  aorta;  6,  left  lung:  7, 
liver ;  8,  stomach ;  9,  ascending  colon ;  10,  bridge  of  tissue  between  stomach,  and  duode- 
num left  by  removing  pylorus;  11,  pancreas;  12,  duodenum  ;  13, 13,  small  intestines;  14, 
fundus  uteri;  15,  bladder;  16,  obturator  internus  muscle ;  17,  descending  colon;  18,  sig- 
moid  flexure;  19,  mesentery;  20,  obturator  externus  muscle:  21,  corpus  cavernosum 
clltondis ;  22,  meatus  urinarius ;  23,  labia  minora ;  24,  labia  majora ;  25,  femur. 


AXATOMY. 


113 


passive  counter- pressure  exercised  by  muscles  and  fasciae  (pp.  99,  101, 
102,  103)  turn  the  child  forward  around  the  pubic  arch. 

The  result  of  parturition  is,  first,  to  dilate  the  vagina  and  the  vulva  ; 
second,  to  tear  the  perineal  body  more  or  less  deeply ;  and  third,  to 
elongate  and  slacken  the  layer  of  loose  connective  tissue  between  the 
entire  displaceable  and  the  entire  fixed  portion  of  the  pelvic  floor, 
thus  predisposing  to  prolapsus  of  the  vagina  and  the  uterus. 

THE  ABDOMINAL  REGIONS. 

By  means  of  certain  imaginary  lines  the  abdomen  is  divided  into 
regions,  the  familiarity  with  which  is  a  great  help  in  gynecological 
examinations  and  the  recording  of  erases.  One  line  is  supposed  to  be 
drawn  across  from  the  highest  point  of  the  iliac  crest  on  one  side  to 
the  corresponding  point  on  the  other.  Another  transverse  line  goes 
from  the  lowest  point  of  the  wall  of  the  thorax  on  one  side  (the  car- 
tilage of  the  tenth  rib)  to  the  corresponding  point  on  the  other  side. 
Finally,  a  line  is  supposed  drawn  perpendicularly  up  from  the  ilio- 
pectineal  eminence.1 

Thus  nine  regions  are  formed,  the  names  and  relations  of  which 
are  seen  in  this  table : 


Right  hypochondriac. 


Epigastric. 


Left  hypochondriac. 


Right  lumbar. 


Umbilical. 


Left  lumbar. 


Right  iliac. 


Hypogastric. 


Left  iliac. 


The  chief  contents  of  each  region  are  best  learned  by  a  study  of 
the  accompanying  figure  (Fig.  103). 

If  we  take  into  consideration  the  weight  of  all  the  organs  pressing 
on  the  bladder,  it  is  evident  that  that  of  a  slightly  enlarged  or  simply 
anteflexed  uterus  is  hardly  of  any  account.  The  discomfort  often 
complained  of  in  the  bladder  under  such  circumstances  is  either  due 
to  an  affection  of  that  organ  itself  or  to  a  nerve  reflex.  The  figure 
illustrates  well  the  large  amount  of  loose  connective  tissue  found  in 
the  pel  vis  (p.  110). 


Different  anatomists  draw  these  lines  somewhat  differently. 


PART  III. 

PHYSIOLOGY. 


CHAPTER  I. 
PUBERTY. 

PUBERTY  and  the  climacteric  are  two  important  epochs  in  woman's 
life,  one  marking  the  beginning,  the  other  the  end,  of  the  fruitful 
period.  Puberty  is  the  change  from  childhood  to  womanhood.  It 
is  a  gradual  development,  which  generally  takes  place  in  the  four- 
teenth or  fifteenth  year  of  the  girl's  life.  At  that  time  the  breasts 
become  larger,  the  uterus  increases  in  size  (p.  33),  the  hips  become 
broader,  and  the  contour  of  the  whole  body  is  rounded  off.  The 
external  genitals  get  their  growth  of  hair,  menstruation  begins,  and 
one  sex  feels  attracted  to  the  other. 

Normal  Development  of  Mammary  Gland  simulating  Tumor. — 
When  at  puberty  the  mammary  glands  become  the  seat  of  greater 
development,  it  happens  often  that  one  lobule  grows  faster  than  other 
parts,  gives  rise  to  some  pain,  and  becomes  a  little  tender.  Thus  a 
more  or  less  distinct  round  or  oval  swelling  is  formed,  which  often 
inspires  fear  and  brings  the  young  girl  to  the  physician,  who  might 
himself  be  deceived  and  make  a  prognosis  or  even  institute  a  treat- 
ment that  might  hurt  his  reputation,  and,  perhaps,  harm  the  patient. 
It  is  enough  to  know  of  the  frequent  occurrence  of  such  a  condition 
in  order  to  avoid  mistakes.  A  wet  compress  covered  with  gutta- 
percha  tissue,  or  rubbing  with  an  anodyne  liniment — e.  g.  chloroform 
mixed  with  twice  the  quantity  of  olive  oil — relieves  the  pain,  and  a 
good  prognosis  disperses  the  anxiety. 

Difference  between  Puberty  and  Nubility. — Puberty  is  the  period 
when  the  possibility  of  reproduction  begins,  but  by  no  means  the 
time  when  it  is  desirable  that  the  girl  should  marry  and  become  a 
mother.  Statistics  show  a  very  great  mortality  among  married  women 
under  twenty  years  of  age.  It  is  evidently  against  nature's  laws  that 
women  should  become  mothers  before  they  are  full-grown.  Their 
uteri  should  have  attained  their  maximum  development,  the  breasts 
should  be  fit  for  nursing,  the  pelves  should  have  reached  a  size  that 

114 


PHYSIOLOGY.  115 

allows  the  passage  of  a  full-grown  child,  the  muscles  should  have 
acquired  strength  enough  to  propel  it,  and  the  whole  system  should 
have  been  endowed  with  full  power  of  resistance  and  endurance.  It 
may,  therefore,  be  stated  that  most  women  should  not  marry  before 
they  are  twenty  years  old. 


CHAPTER  II. 
MENSTRUATION  AND  OVULATION. 

MENSTRUATION  is  the  discharge  of  a  bloody  -fluid  from  the  cavity 
of  the  uterus  at  regular  intervals.  It  is  also  called  the  menses,  the 
catamenia,  the  menstrual  period,  the  monthly  sickness,  the  monthly 
flow,  courses,  or  turns. 

This  phenomenon  is  peculiar  to  woman  and  some  monkeys.1  It 
is  probably  due  .to  the  erect  position,  which  necessitates  a  harder  tis- 
sue of  the  womb,  and  excludes  the  presence  of  the  enormously  devel- 
oped lymphatic  system  which  is  found  in  the  horizontal  animals, 
together  with  a  flabby  uterus.2 

The  menstrual  flow  commences  in  most  women  in  the  temperate 
zone  between  the  fifteenth  and  seventeenth  years  of  their  life.  It 
begins  earlier  in  warm  climates  than  in  cold,  earlier  in  cities  than 
in  the  country,  and  earlier  in  the  higher  walks  of  society  than  in  the 
lower.3  It  returns  in  periods  of  twenty-eight  days,4  and  lasts  on  an 
average  four  days.  The  amount  varies  very  much.  Four  or  five  ounces 
are  said  to  be  the  average.5  It  is  increased  by  exercise,  corporeal  work, 
chalybeates,  and  stimulants.  The  blood  differs  from  that  from  other 
sources  by  a  more  or  less  considerable  admixture  of  mucus  and  epi- 
thelial cells.  It  has  also  the  peculiar  "  heavy  "  odor  characteristic  of 
the  genitals.  It  comes  from  the  mucous  membrane  of  the  body  of 
the  uterus  and  the  tubes,  while  the  cervix  has  no  part  in  the  process 
of  menstruation.  Before  its  appearance  the  woman  feels  a  certain 
heaviness  in  the  lumbar  region,  while  pain  is  always  a  sign  of  an 
abnormal  condition.  Often  the  breath  has  an  unpleasant  odor  during 

1  Bland  Sutton,  BriLGyn.  Jour.,  Nov.,  1886,  Part  vii.  p.  285. 

2  A.  W.  Johnstone,  Amer.  Gyn.  Trans.,  1889,  vol.  xiv.  p.  284. 

3  Special  statistics  are  found  in  Hannover's  Om  Menstruationens  Betydning,  Copen- 
hagen, 1851,  p.  18 ;  and  T.  A.  Emmet,  The  Principles  and  Practice  of  Gynecology,  2d 
ed.,  1880,  p.  153  et  seq.     In  a  total  of  2330  cases,  Dr.  E.  found  the  average  age  at 
the  first  menstruation  to  be  14.23  years,  but,  his  patients  being  from  the  "  better 
classes,"  this  average  is  too  low. 

4  Most  women  are  entirely  unreliable  in  regard  to  their  statement  of  the  occur- 
rence of  menstruation.     Very  commonly  they  state  that  they  have  it  on  a  certain 
date  of  each  month.     It  is,  therefore,  advisable  for  the  gynecologist  to  keep  book 
himself  of  the  beginning  and  the  end  of  the  periods  of  those  under  his  treatment. 
Thus  many  an  error  is  proved,  many  a  complaint  settled. 

5Funcke,  Lehrbuch  der  Physiologic,  4th  ed.,  1866,  vol.  ii.  p.  991. 


116 


DISEASES  OF  WOMEN. 


the  period.  If  menstruation  has  been  evolved  from  the  rut  in 
animals,  it  has  changed  very  materially.  While  female  animals 
only  admit  the  male  during  this  period  of  heat,  woman  not  only  has 
an  aversion  for  sexual  intercourse  during  her  menstruation,  but  the 
act  performed  during  the  catamenial  period  exposes  both  sexes  to  dis- 
ease— the  woman  to  retro-uterine  hematocele,  the  man  to  urethritis 
and  orchitis.  As  a  rule,  menstruation  ceases  during  pregnancy  and 
lactation,  but  exceptions,  especially  from  the  latter  rule,  are  by  no 
means  infrequent. 

The  anatomical  basis  of  menstruation  is  a  regularly  recurrent  de- 
velopment of  the  endometrium.1     About  a  week  before  menstruation 

FIG.  104. 


Uterus  during  Menstruation  (Courty).  Cut  open  to  show  the  swelling  of  the  whole  organ, 
and  particularly  the  mucous  membrane:  A,  mucous  membrane  of  cervix  ;  B,  C,  mucous 
membrane  of  corpus,  much  thickened ;  D,  muscular  layer ;  E,  uterine  opening  of  tube ; 
F,  os  internum  (the  mucous  membrane  tapers  down  to  these  openings). 

sets  in  the  raucous  membrane  of  the  uterus  begins  to  swell,  so  that 
from  2  or  3  millimeters  (|  inch)  in  thickness  it  becomes  6  or  7  milli- 
meters (J  inch)  thick.  It  acquires  the  greatest  thickness  on  the  mid- 
dle of  the  surfaces  and  fundus,  and  falls  gradually  off  toward  the 
edges  (Fig.  104).  Its  surface  becomes  wavy  in  consequence  of  the 

1  Leopold,  Archiv  fur  Oyniik.,  1877,  vol.  xi.  p.  110  et  seq. 


PHYSIOLOGY. 


117 


disproportion  between  it  and  the  underlying  muscular  tissue.  Its 
arteries  become  much  enlarged  and  form  spirals.  There  is  likewise 
so  great  a  development  of  capillaries  immediately  under  the  epithelium 
that  they  form  a  plexus  discernible  with  the  naked  eye.  On  the 
other  hand,  there  are  only  lew  and  small  veins.  The  utricular  glands 
become  much  wider  and  elongated,  forming  spiral-  and  zigzag-shaped 
tubes.  The  tissue  itself  is  composed  of  connective-tissue  cells  inter- 
spersed with  an  enormous  amount  of  round  cells,  like  lymph-corpus- 

FIG.  105. 


Microscopical  Section  of  Endometrium  of  a  Menstruating  Woman,  aged  twenty,  showing 
utricular  follicles  denuded  of  epithelium,  and  one  still  containing  the  epithelial  cast 
(Johnstoue). 

cles,  and  giant-cells  with  many  nuclei.  According  to  Leopold,  these 
cells  are  found  in  a  condition  of  active  proliferation,  while,  according 
to  Johnstone,  who  has  worked  with  much  more  powerful  lenses,  the 
corpuscular  elements  are  formed  from  granules  in  the  threads  of  con- 
nective tissue  forming  the  bulk  of  the  mucous  membrane  (Fig.  47, 
p.  52).  Before  menstruation  begins  the  blood-pressure  is  increased 
(Stephenson).  Some  of  the  capillaries  near  the  surface  burst  and  the 
blood  escapes,  partly  into  the  tissue,  forming  small  extravasations, 
partly  on  the  surface,  lifting  up  and  tearing  off  the  epithelium.  The 
epithelium  is  also  shed  in  that  part  of  the  utricular  glands  that  lies 
nearest  to  the  cavity  of  the  uterus  (Fig.  105).  Five  or  six  days  after 
the  beginning  of  menstruation  the  regeneration  of  the  epithelium 


118  DISEASES  OF  WOMEN. 

begins  from  the  utricular  glands.  Eight  or  nine  days  after  the 
beginning  of  menstruation  the  regeneration  is  already  completed. 
The  glands  are  no  longer  twisted  into  spirals,  the  arteries  have  become 
smaller,  the  capillary  net  shrinks,  the  scars  in  the  capillaries  heal,  and 
the  whole  surface  is  covered  with  epithelium.  Most  of  the  corpuscu- 
lar elements  have  disappeared. 

The  tubes  take  part  in  the  process  of  menstruation.  Their  mucous 
membrane  is  swollen,  the  epithelium  is  shed  in  some  places,  and  they 
are  filled  with  a  thin  bloody  fluid  containing  blood -corpuscles  and 
cast-off  epithelial  cells. 

From  this  brief  description  of  the  condition  of  the  endometrium 
during  menstruation  it  is  easy  to  draw  several  practical  conclusions. 
We  can  understand  how  easily  we  can  do  harm  by  the  introduction 
of  the  sound  during  the  catamenia  ;  how  a  normal  menstruation  may 
become  a  pathological  hemorrhage,  if  the  woman  works  hard  or  takes 
much  exercise;  and  how  the  menstrual  discharge  may  be  intermit- 
tent— a  thing  that  appears  so  surprising  to  many  women. 

Ovulaiion. — In  mammalia  the  connection  between  the  processes 
that  take  place  in  the  ovaries  and  in  the  womb  are  perfectly  known. 
One  or  more  Graafian  follicles  become  mature  and  burst  before  each 
recurrence  of  rut.  The  ovum  escapes  into  the  tube  and  passes  into 
the  uterus,  the  mucous  membrane  of  which  is  in  a  similar  condition 
in  regard  to  the  presence  of  medullary  elements  (the  bodies  that  look 
like  lymph-corpuscles)  to  that  of  a  menstruating  woman.1  If  copu- 
lation takes  place,  the  ovum  meets  the  spermatozoids  somewhere  on 
this  passage  from  the  ovary  through  the  tube  to  the  uterus,  and,  as  a 
rule,  impregnation  takes  place.  In  the  ovaries  are  found  as  many 
corpora  lutea  as  there  are  fetuses  in  the  uterus.  We  do  not  know 
if  a  similar  thing  takes  place  in  women ;  that  is  to  say,  we  do  not 
know  if  ovulatiou  is  a  periodical  process,  and,  if  so,  we  do  not  know 
if  the  cyclus  is  the  same  as  for  menstruation.  That  there  is  some 
connection  between  the  two  seems  to  be  proven  by  the  correspondence, 
generally  admitted,  between  the  time  elapsed  since  the  beginning  of 
menstruation  and  the  degree  of  development  of  the  corpus  luteum 
(p.  71).  But  this  correspondence  is  denied  by  others,  who  have  large 
experience  in  the  removal  of  the  uterine  appendages.2 

We  know  for  sure  that  a  single  coition  at  any  time  may  result  in 
the  impregnation  of  a  woman,  but  the  likelihood  of  impregnation  is 
much  greater  shortly  after  or  shortly  before  menstruation  than  mid- 
way between  the  end  of  one  menstrual  period  and  the  beginning  of 
the  next.  Of  the  two  terms,  that  preceding  a  menstruation  seems, 
again,  to  give  the  best  chances  for  impregnation.  This  is,  among 
others,  proved  by  embryology.  In  the  young  embryo  the'develop- 

1  A.  W.  Johnstone,  Brit.  Ned.  Jour.,  Nov.,  1887,  Part  xi.  p.  384. 

2  Lawson  Tait,  Diseases  of  Women,  Philadelphia,  1889,  pp.  312-317. 


PHYSIOLOGY.  119 

meut  is  so  rapid  that  an  interval  of  three  weeks  makes  an  enormous 
difference  in  the  condition  of  the  organs.  In  this  way  it  was  found 
that  three-fourths  of  young  embryos  corresponded  to  the  first  skipped 
menstruation,  and  only  one-fourth  to  the  end  of  the  preceding.1 

The  fact  that  a  woman  may  be  impregnated  at  any  time  does,  how- 
ever, not  prove  that  an  ovum  is  detached  at  that  time,  for  we  know 
that  both  ovum  and  spermatozoids  may  be  preserved  for  some  time 
in  the  genital  canal.  The  first  has  been  found  on  the  fourth  day  of 
menstruation  in  the  uterine  part  of  the  tube  (Hyrtl 2)  and  in  another 
case  1^  inches  above  the  internal  os  (Beuham2).  How  long  it  stays 
in  the  uterus  and  keeps  its  faculty  of  becoming  fertilized  is  unknown. 
We  know  as  little,  or  still  less,  about  the  time  the  spermatozoids 
retain  their  fructifying  power  in  the  genitals  of  woman,  but  analogy 
from  animals  teaches  that  this  is  probably  a  longer  one.  They  have 
been  found  alive  in  the  os  on  the  ninth  day  after  coition.3  We  can, 
therefore,  easily  imagine  that  in  the  case  of  impregnation  taking  place 
in  consequence  of  a  single  connection  in  the  middle  of  the  intermen- 
strual  period,  the  spermatozoids  are  preserved  and  meet  an  ovum 
detached  at  the  following  menstruation. 

On  the  other  hand,  it  is  a  fact  that  copulation  may  be  performed 
on  any  day  of  the  intermenstrual  period  without  resulting  in  preg- 
nancy. 

Influence  of  Operations  on  Menstruation. — It  is  very  common  that 
during  the  first  days  after  the  removal  of  the  ovaries  a  bleeding  takes 
place  from  the  uterus,  even  if  the  patient  had  menstruated  just  before 
the  operation.4  In  some  cases  the  hemorrhage  occurs  from  other 
organs :  I  have  seen  it  come  from  the  bladder,  the  rectum,  and  the 
nose.  This  determination  of  normal  or  vicarious  menstruation  is 
probably  due  to  the  irritation  exercised  on  the  nerves  in  the  pedicle 
by  the  tightening  of  the  ligature. 

On  the  other  hand,  menstruation  ceases  in  most  cases  after  double 
ovariotomy  or  oophorectomy,  but  exceptions  from  this  rule  are  by  no 
means  rare.  There  are  cases  in  which  menstruation  is  repeated  with 
more  or  less  regularity  for  several  months  or  even  years.  In  other 
•  cases  menstruation  does  not  occur  during  the  first  three  or  six  months 
following  the  operation,  but  then  it  reappears  for  a  year  or  two, 
occasionally  in  the  shape  of  a  severe  flooding.5 

1  His,  Anatomie  menschlicher  Embryonen,  Leipzig,  1882,  ii.  p.  73.     The  whole  num- 
ber, however,  being  only  sixteen,  this  argument  loses  some  of  its  weight. 

2  Leopold,  /.  c.,  p.  121. 

3  R.  Percy,  of  New  York,  Amer,  Jour.  Med.  Sci.,  July,  1876,  p.  158. 

4  In  order  to  avoid  this  extra  loss  of  blood,  which  in  anemic  patients  may  turn  the 
scales,  Mr.  Tait  advises  to  operate  immediately  before  or  during  menstruation  (/.  c., 
p.  312). 

5 George  Engelmann  of  St.  Louis,  "Menstruation  and  the  Removal  of  Both 
Ovaries,"  Trans.  Southern  Surgical  and  Gynecol.  Assoc.,  Sept.,  1889;  reprint,  p.  1. 
This  is  not  in  itself  a  proof  against  the  ovulation  theory,  for  if  the  presence  of  a 


120  DISEASES  OF  WOMEN. 

At  the  time  the  extra-peritoneal  treatment  of  the  pedicle  was  yet 
in  vogue  I  saw  menstruation  after  ovariotomy  accompanied  by  bleed- 
ing from  the  tube  in  the  stump.  With  the  present  iutraperito- 
neal  method  there  may,  therefore,  occasionally  occur  a  retro-uterine 
hematocele  under  such  circumstances. 

According  to  Tait,  the  removal  of  the  Fallopian  tubes  is  of  much 
greater  importance  in  bringing  on  the  menopause  than  that  of  the 
ovaries ;  but  it  is  not  unlikely  that  the  influence  of  the  removal  of 
the  tubes  is  again  due  to  a  large  nerve-trunk  which  is  seen  running 
to  the  uterus  in  the  broad  ligament,  in  the  angle  between  the  round 
ligament  and  the  tube.1  When  the  object  of  the  operation  is  to  bring 
on  the  menopause,  special  care  should,  therefore,  be  taken  to  go  close 
up  to  the  uterus  and  include  this  nerve  in  the  ligature ;  and  in  cases 
in  which  the  removal  of  the  uterus  or  its  appendages  proves  impos- 
sible, it  is  advisable  to  ligate  the  tubes,  including  the  nerve. 

Theory  of  Menstruation. — The  cause  of  menstruation  is  unknown. 
Most  likely  it  has  a  yet  unknown  centre  in  the  central  organs  of  the 
nervous  system.  According  to  Johnstone,  menstruation  is  a  necessity 
in  women  and  erect  animals,  because  there  are  not  sufficient  lym- 
phatics to  carry  off  the  lymph-corpuscles.  The  uterus  is,  according 
to  him,  a  hollow  lymphatic  gland  without  a  lymph-stream,  and  his 
definition  of  menstruation  is,  "  a  periodical  washing  away  of  those 
corpuscles  which  are  too  old  to  make  a  placenta."  (Compare  p.  50, 
foot-note.)  If  there  is  any  connection  between  ovulation  and  men- 
struation, both  are  controlled  by  a  common  impulse  from  the  central 
nervous  system. 

In  some  patients  I  have  observed  that  alternately  one  and  the  other 
ovary  undergoes  a  regular  swelling  at  the  time  of  every  menstruation, 
but  whether  the  same  is  the  case  in  healthy  women  I  do  not  know. 

third  ovary  of  the  size  of  the  normal  ones  is  so  rare  as  not  to  count  in  this  connec- 
tion, small  supernumerary  ovaries  have  been  found  twenty-three  times  in  500 
bodies  (Beigel  j.  Another  explanation  is  that  a  part  of  the  two  large  ovaries  has  been 
left  behind — a  thing  that  sometimes  is  unavoidable.  But  perhaps  the  presence  of 
ovarian  tissue  is  not  needed  at  all  for  the  recurrence  of  menstruation.  Tait  has  seen 
menstruation  recur  regularly  for  many  years  in  a  case  of  Porro's  operation  in  which 
ovaries,  tubes,  and  most  of  the  uterus  were  removed  (L  c.,  p.  320).  Rut  can  also 
occur  in  animals  after  complete  removal  of  the  ovaries  ( Barthele'my,  Jour,  de  Mede- 
dne  veterinaire  ;  Med.  Record,  Sept.  27,  1890,  p.  368). 
1  Johnstone,  Brit.  Med.  Jour.,  Nov.,  1887,  p.  387. 


PHYSIOLOGY.  121 


CHAPTER   III. 

COPULATION. 

COPULATION  is  the  act  by  which  the  male  and  female  bodies  are 
sexually  united.  Under  normal  circumstances  it  is  preceded  by  sex- 
ual appetite  or  desire.  All  its  phases,  perhaps  with  the  exception  of 
the  desire,  seem  to  be  much  less  pronounced  in  woman  than  in  man. 
The  clitoris,  the  vestibulo-vagiual  bulbs,  and  perhaps  the  inner  geni- 
tal organs  enter  into  a  state  of  erection.  Friction  between  the  male 
and  female  copulative  organs  causes  a  peculiar  pleasurable  sensation, 
which  ends  in  orgasm,  the  acme  of  nervous  excitement,  which  seems 
to  be  weaker  in  the  female  than  in  the  male,  and  is  altogether  absent 
in  some  women,  who  nevertheless  are  capable  of  being  impregnated. 
The  orgasm  is  accompanied  by  an  ejaculation  of  a  mucous  fluid  from 
the  glands  of  the  vulva.  If  orgasm  is  less  pronounced  than  in  the 
other  sex,  it  leaves  far  less  feeling  of  exhaustion  than  in  man.  It  is 
followed  by  relaxation  which  at  any  time  may  again  give  place  to  new 
excitement  and  erection.  This  difference  is  easy  to  understand  when 
we  take  into  consideration  the  difference  between  the  fluids  ejaculated 
and  the  profound  shock  sustained  during  orgasm  by  the  central  ner- 
vous system  in  the  male. 

The  disturbance  of  these  normal  conditions  which  makes  copulation 
painful  or  impossible  is  called  dyspareunia,1  and  may  be  caused  by 
many  different  affections  or  malformations  of  the  genitals  or  other 
organs. 

CHAPTER   IV. 

FECUNDATION. 

FECUNDATION,  or  FERTILIZATION,  is  the  union  of  the  male  and  the 
female  generative  elements,  the  spermatozoid  and  the  ovum,  by  which 
in  the  latter  commences  the  formation  of  a  new  individual.  It  is 
likely  that  the  two  elements,  as  a  rule,  meet  in  the  tubes,  although 
the  well-authenticated  phenomenon  of  ovarian  pregnancy  proves  that 
the  combination  may  take  place  in  the  ovary,  and  in  mammalia  the 
spermatozoids  are  found  on  it  within  twenty-four  hours  after  coition. 

1  Robert  Barnes,  A  Clinical  History  of  the  Medical  and  Surgical  Diseases  of  Women, 
London,  1873,  p.  61. 


122  DISEASES  OF  WOMEN. 

In  animals  the  ovum  is  no  longer  capable  of  fertilization  when  it  has 

FIG.  106. 


Portions  of  the  ova  of  Asterias  glacialis,  showing  the  approach  and  fusion  of  the  spermatozoon 
with  the  ovum  (Hertwig) :  a,  fertilizing  male  element ;  6,  elevation  of  protoplasm  of  egg ; 
6',  b",  stages  of  fusion  of  the  head  of  the  spermatozoon  with  the  ovum. 

left  the  upper  part  of  the  tubes.     It  seems,  therefore,  highly  improb- 

FIG.  107. 


Fertilized  Ova  of  Echinus  (Hertwig):  A,  The  male  (a)  and  the  female  pronucleus  (b)  are 
approaching;  in  B  they  have  almost  fused.  C,  ovum  of  Echinus  after  completion  of 
fertilization;  s.n,  segmentation-nucleus. 

able  that  in  woman  the  ovum  should  retain  the  possibility  of  being 


PHYSIOLOGY.  123 

fecundated  for  weeks  after  it  has  left  the  ovary,  whilst  no  fact  is 
known  that  would  conflict  with  the  supposition  that  the  spermato- 
zoids  keep  their  vitality  for  weeks  in  the  folds  of  the  ampulla,  and, 
on  the  contrary,  such  possibility  is  absolutely  proved  in  animals.1 
If  union  of  the  two  elements  took  place  in  the  cervix,  the  ovum 
would  be  lost,  as  this  part  of  the  uterus  is  not  fit  for  the  formation 
of  a  placenta. 

The  analogy  from  animals  makes  it  also  highly  probable  that  a  part 
of  the  spermatozoid  enters  through  the  zona  pellucida  and  combines 
with  the  germinal  vesicle  (p.  70),  so  that  the  formation  of  the  new 
individual  begins  by  the  physical  union  of  material  derived  from  the 
father  as  well  as  from  the  mother  (Figs.  106  and  107).  This  leads 
us  at  least  one  step  farther  in  the  comprehension  of  the  wonderful 
transmission  through  heredity  of  physical  and  mental  peculiarities, 
aptitudes,  and  acquired  talents,  as  well  as  diseases,  from  the  father  to 
his  offspring. 


CHAPTER  V. 
THE  CLIMACTERIC. 

THE  CLIMACTERIC — also  called  the  menopause,  or  change  of  life — is 
the  end  of  the  fruitful  part  of  woman's  existence.  Like  puberty,  it 
is  not  a  momentary  nor  a  single  event.  It  comes  on  gradually,  ex- 
tending over  a  period  of  two  or  three  years,  and  if  the  cessation  of 
menstruation  is  the  most  characteristic  symptom  of  it,  it  reverberates 
through  the  whole  system,  causing  considerable  physical  and  mental 
changes.  It  comprises  the  time  when  menstruation  begins  to  be 
irregular,  gradually  diminishes,  and  finally  ceases  altogether.  In 
most  women  the  menopause  supervenes  when  they  are  from  forty-five 
to  fifty  years  old,  and  the  length  of  the  fruitful  period  is  in  most 
women  thirty-four  years.  Those  who  begin  to  menstruate  early 
(under  sixteen  years)  continue,  as  a  rule,  longer  than  those  who  have 
their  first  menstruation  late  (after  sixteen).  From  this  rule  there  is  only 
one  exception,  and  that  is  due  to  the  influence  of  climate  :  in  cold  cli- 
mates menstrual  life  begins  and  ceases  late,  while  in  hot  climates  it 
begins  and  ceases  early.  The  fruitful  period  is  longer  in  those  women 
who  have  borne  children  and  nursed  them  themselves  than  in  nul- 
Iipara3  and  those  who  have  not  nursed  their  children.  On  the  other 
hand,  early  sexual  intercourse  and  a  rapid  sequence  of  childbirths  or 
miscarriages  shorten  the  period  of  fertility.  It  is  shorter  in  the  labor- 

1  His,  Anatomie  menscfdicher  Embryonen,  Leipzig  1880,  i.  p.  167. 


124  DISEASES  OF  WOMEN. 

ing  classes  than  in  women  who  lead  an  easy  life.  It  is  likewise 
shorter  in  fat  women  than  in  thin,  and  shorter  in  weak  women  than  in 
strong.  Those  who  suffer  from  chronic  metritis  or  are  weakened  by 
uterine  hemorrhages  arrive  sooner  at  the  menopause  than  healthy 
women.  Often  it  is  brought  on  suddenly  by  severe  diseases,  such  as 
cholera,  typhoid  fever,  malaria,  or  a  fall,  a  blow,  a  great  fright,  or 
deep  mental  depression.  Such  sudden  entrance  of  the  menopause  is, 
as  a  rule,  accompanied  by  especially  violent  disturbances  in  the  whole 
organism,  and  it  is  therefore  much  better  for  a  woman  when  it  comes 
on  gradually. 

The  most  serious  side  of  the  climacteric  is  that  it  is  the  time  when 
carcinoma  most  frequently  appears  in  the  uterus  or  the  breasts. 

The  first  symptom  of  the  approaching  menopause  is  irregularity 
in  the  menstrual  flow  in  regard  to  time  and  quantity.  As  a  rule,  the 
interval  between  two  menstrual  periods  becomes  longer — say,  six  or 
eight  weeks — but  sometimes,  on  the  contrary,  menstruation  becomes 
more  frequent.  The  quantity  of  the  discharge  diminishes,  but  occa- 
sionally profuse  hemorrhages  occur.  Menstruation  lasts  longer — say 
six  or  eight  days.  Most  of  the  accompanying  symptoms  may  be 
referred  to  active  or  passive  hyperemia  (congestion  or  stasis).  Thus 
we  find  congestion  in  the  head,  causing  a  red  face,  headache,  indis- 
tinct vision,  a  buzzing  sound  in  the  ears,  vertigo,  restless  sleep  dis- 
turbed by  harassing  dreams,  and  bleeding  from  the  nose.  The  passive 
hyperemia  of  the  intestinal  tract  produces  catarrh  of  the  stomach  and 
of  the  intestines,  hyperemia  of  the  liver,  with  icterus,  swelling  and 
bleeding  of  the  hemorrhoidal  veins.  The  hyperemia  of  the  lungs 
causes  bronchial  catarrh  and  attacks  of  dyspnea.  That  of  the  kidneys 
shows  itself  in  sediment  in  the  urine.  Leucorrhea  is  very  frequent. 
The  skin  is  frequently  the  seat  of  flashing  heat  and  profuse  perspira- 
tion. Acne  rosacea  appears  often  in  the  face  ;  there  may  be  intoler- 
able itching,  burning,  or  smarting  sensations  all  over  the  body,  and 
the  vulva  may  be  the  seat  of  a  most  distressing  pruritus.  The  nerv- 
ous system  shows  signs  of  a  profound  shock.  Besides  the  symptoms 
already  mentioned  in  reference  to  the  head  and  skin,  the  patient  often 
complains  of  backache  and  neuralgia;  sometimes  tremor  occurs  in 
her  limbs;  she  suffers  from  palpitations;  her  temper  is  subject  to 
great  and  sudden  changes ;  the  sexual  appetite  is  often  inconveniently 
increased ;  and  she  may  become  delirious  or  even  insane. 

A  peculiar  functional  affection  of  the  heart  has  been  observed :  it 
is  characterized  by  palpitations,  dyspnea  on  exertion,  a  feeling  of  dis- 
tress in  the  region  of  the  heart,  faintness  or  syncope,  a  very  rapid 
pulse  without  any  rise  in  temperature,  edema  at  the  malleoli  and  the 
hypogastric  region,  and  pallor  of  the  face.  The  attacks  usually  last 
a  week.  The  disease  begins  and  disappears  gradually. 

The  whole  appearance  of  the  person  changes  often  at  the  meno- 


PHYSIOLOGY.  125 

pause.  Most  women  become  stout,  but  some  lose  flesh.  Sometimes 
gout  makes  its  appearance. 

Considerable  anatomical,  changes  take  place  in  the  genitals.  The 
uterus  becomes  atrophic.  Sometimes  the  external  or  internal  os  or 
both  close,  and  if  at  the  same  time  there  is  catarrh  of  the  mucous 
membrane,  the  mucus  accumulates,  forming  hydrometra,  or,  if  gases 
are  developed  in  the  fluid,  physometra.  if  both  the  internal  and 
external  os  close  and  a  catarrhal  discharge  takes  place  both  in  the 
body  and  the  cervix,  a  characteristic  swelling  is  formed,  composed  of 
two  globes  separated  by  a  transverse  furrow  (uterus  bicameratus 
vetularum).  The  mucous  membrane  becomes  thin  and  loses  its  cor- 
puscular elements  (Fig.  51).  Sometimes  a  vessel  ruptures  in  the  fun- 
dus  or  posterior  wall,  causing  an  extravasation  of  blood  (apoplexy  of 
the  uterus). 

The  ovaries  become  small  and  hard  ;  the  epithelium  is  lost  on  large 
areas ;  the  follicles  disappear,  and  are  replaced  by  dense  fibrous  con- 
nective tissue. 

The  tubes  become  both  thinner  and  shorter,  and  not  seldom  the 
walls  grow  together  in  different  places. 

In  the  breasts  the  glandular  tissue  disappears,  and  they  become 
atrophic,  or  if  they  retain  their  size,  or  even  become  larger,  it  is  due 
to  the  development  of  fat.  Sometimes  a  serous  fluid  is  found  in  them 
before  the  gland  has  all  been  absorbed — a  circumstance  which,  to- 
gether with  abnormal  sensations  in  the  abdomen,  tympanites,  and  the 
cessation  of  the  menses,  often  lead  the  patient,  and  sometimes  the 
physician,  to  the  erroneous  belief  that  she  is  pregnant. 

Treatment — Although  the  climacteric  is  a  physiological  process, 
normally  occurring  in  every  woman's  life  if  it  is  sufficiently  extended, 
the  dangers  with  which  it  threatens  are  so  serious,  and  the  normal 
condition  passes  so  easily  and  frequently  into  the  domain  of  dis- 
ease, that  the  physician  is  often  consulted  about  it.  The  treatment 
of  the  real  diseases  connected  with  it  will  be  discussed  in  later  chap- 
ters, under  the  diseases  of  the  different  organs  affected,  or  must  be 
looked  for  in  works  on  the  practice  of  medicine.  Here  we  can  only 
indicate  a  few  points,  especially  in  reference  to  hygiene. 

A  chief  point  is  to  keep  the  Bowels  open,  preferably  by  means  of 
aperient  salts  or  waters.  Sometimes  enemas  of  plain  water  or  muci- 
laginous and  oily  substances  or  glycerin  may  advantageously  be  com- 
bined with  or  substituted  for  the  aperient  medicine.  Derivation  to 
the  skin  by  washing  the  whole  body  with  cold  water  and  rubbing 
the  skin  well  with  Turkish  towels  is  both  pleasant  and  useful.  For 
the  loaded  urine  it  is  good  to  drink  a  syphonful  of  Vichy,  Rhens, 
or  Seltser  water  in  the  course  of  the  day,  or  to  take  bicarbonate  of 
soda  (3ss)  in  a  tumblerful  of  water:  The  congestion  of  the  head  and 
visual  disturbance  are  often  much  benefited  by  the  use  of  hot  foot- 


126  DISEASES  OF  WOMEN. 

baths,  with  or  without  mustard,  of  the  cold  eye-douche  five  minutes 
three  times  a  day,  combined  with  scarification  of  the  cervical  portion. 
A  glycerin  pledget  introduced  morning  and  evening  into  the  vagina 
may  also  relieve  congested  organs  by  causing  a  watery  discharge.  A 
lukewarm  general  bath  taken  two  or  three  times  a  week  keeps  the 
skin  in  good  order  and  tranquillizes  the  nerves.  The  diet  should  be 
bland,  but  must  vary  according  to  the  constitution.  In  those  women 
who  have  a  tendency  to  stoutness  it  ought  to  be  as  much  restricted  as 
possible,  and  all  fat-producing  food  (cereals  and  sugar)  ought  especially 
to  be  taken  in  very  small  quantities;  milk  and  beer  are  prohibited. 
Fish,  meat,  green  vegetables,  lettuce  salad,  and  juicy  fruits  ought  to 
constitute  the  bill  of  fare.  Tea  and  coffee  ought  only  to  be  taken  weak. 
Upon  the  whole,  the  less  the  woman  drinks  the  better,  for  even  water 
makes  her  fat.  Alcoholic  stimulants  are  best  avoided  altogether,  but 
if  there  are  special  indications  making  their  use  desirable,  or  the 
patient  has  a  craving  for  them,  a  light  acid  white  wine  (Moselle), 
mixed  with  plain  water  or  a  mild  alkaline  water,  will  do  least  harm. 
When  the  stoutness  takes  the  proportions  of  pronounced  obesity,  a  still 
stricter  diet  is  necessary  (Banting  cure),  and  special  treatment  at  certain 
mineral  springs  (Carlsbad.  Marienbad,  Tarasp)  may  be  indicated. 

Those  more  exceptional  women  who  lose  flesh,  must  be  well  fed 
and  have  chocolate  and  plenty  of  milk  to  drink,  if  they  can  digest 
them.  Cereals  ought  to  be  a  chief  part  of  their  diet-list,  but  all 
sorts  of  animal  food  ought  to  be  given  besides. 

As  a  sudden  suppression  of  the  menses  is  particularly  dangerous, 
the  patient  ought  to  take  special  precautions  in  that  respect  during 
the  climacteric.  She  must  beware  of  cold  feet  or  a  wet  skin  Mhen 
she  has  her  menses,  not  wash  the  genitals  with  cold  water,  and  still 
less  take  a  cold  bath  when  the  menses  are  present. 

As  congestion  of  the  pelvic  organs  might  cause  hemorrhage,  she 
should  abstain  from  sexual  intercourse.  When  first  the  menopause 
is  well  established  marital  relations  may  be  resumed  without  danger. 

The  mental  diet  is  of  no  less  importance  than  the  physical.  The 
physician  may  relieve  much  unnecessary  anxiety  by  giving  a  good 
prognosis.  The  patient  should  occupy  her  mind  by  useful  work,  and 
exercise  as  much  self-control  as  her  mental  condition  and  acquired 
habits  will  allow. 

When  hemorrhage  supervenes,  it  ought  to  be  checked  just  as  under 
other  circumstances  when  a  proper  amount  of  blood  corresponding 
to  a  menstrual  period  has  been  discharged.  For  this  purpose  we  use 
hot  douches,  an  ice-bag  over  the  hypogastric  region,  tamponade,  and 
drugs  that  have  that  effect  (see  Menorrhagia) ;  and  the  patient  ought  to 
be  kept  in  bed  lightly  covered  in  a  cool  room,  and  on  cool,  spare  diet. 

The  above-mentioned  menstrual  cardiopathy  is  treated  with  digitalis 
and  other  heart  tonics. 


PART  IV. 

ETIOLOGY  IN  GENERAL. 

THE  causes  of  gynecological  diseases  may  be  divided  into  predis- 
posing and  exciting. 

Predisposing  Causes. — The  first  class,  although  more  remote  in 
their  effect,  are  more  important  on  account  of  their  frequency. 
Heredity  may  play  a  double  role,  either  that  the  same  defect  that  is 
found  in  the  mother  is  transmitted  to  her  daughter,  especially  mal- 
formations and  malignant  diseases,  or  that  the  child  inherits  a  gener- 
ally weak  constitution  from  one  or  both  of  her  parents,  which,  in 
combination  with  her  sex  and  the  other  predisposing  factors,  gives 
rise  to  diseases  of  the  genitals  and  pelvic  organs.  In  the  latter  respect 
it  must  be  noted  that  children  of  parents  advanced  in  life  at  the  time 
of  their  procreation  as  a  rule  are  less  vigorous  than  those  engendered 
in  younger  years. 

Education  has  great  influence  in  the  development  of  gynecological 
diseases.  Too  great  assiduity  in  study  in  early  youth  concentrates 
the  nerve-energy  on  the  brain,  and  deprives  the  uterus  and  ovaries  of 
their  share  at  a  time  when  these  organs  are  undergoing  an  enormous 
development,  and  preparing  for  the  important  functions  of  womanhood 
and  motherhood.  Too  great  interest  in  and  practice  of  music,  by  its 
profound  effect  on  the  emotions  and  the  constantly  repeated  physical 
thrill  in  the  nerves,  is  particularly  dangerous. 

Everything  that  causes  active  or  passive  hyperemia  of  the  pelvic 
organs  is  a  source  of  disease.  In  this  category  belongs  sexual  excite- 
ment brought  on  by  reading  prurient  novels ;  by  looking  at  obscene 
pictures ;  by  seeing  representations  on  the  stage  that  aim  at  the  ex- 
posure of  so  much  of  the  body  as  existing  laws  and  public  opinion 
will  permit;  by  masturbation,  sapphism  (the  same  as  tribadism),  sod- 
omy, and  even  normal  coition  if  performed  too  violently. 

The  neglect  of  the  skin,  by  which  a  chief  emunctory  is  nearly 
blocked  up,  is  hardly  found  in  the  better  classes  in  this  country,  but 
is  exceedingly  common  among  the  poorer  women,  especially  immi- 
grants, of  certain  nationalities.1 

Insufficient  exercise  and  lack  of  open  air  are  a  frequent  cause  of  dis- 
ease, and  favor  the  stagnation  of  blood  in  the  pelvis ;  but  in  this 

1  The  Jewesses  from  Russian  Poland  in  my  dispensary  experience  exceed  all  others, 
and  make,  in  fact,  the  impression  of  never  bathing  or  washing  their  body. 

127 


128  DISEASES  OF  WOMEN. 

respect,  as  also  in  regard  to  food,  a  great  change  has  taken  place  in 
the  higher  classes  during  the  last  decade.  The  ideal  of  the  American 
girl  is  no  longer  to  be  thin  and  pale.  The  young  men  having  taken 
an  ever-increasing  interest  in  athletics  and  all  sorts  of  sports,  most 
of  which  are  cultivated  in  the  open  air,  the  girls  do  not  want  to  stay 
behind.  The  dull  croquet  has  speedily  been  followed  by  the  lively 
tennis;  muscular  strength  is  developed  by  swimming,  riding,  fencing, 
skating,  and  ballet-dancing ;  and  now  the  girls  begin  even  to  have 
gymnasiums  of  their  own,  where  every  part  of  the  body  may  be 
developed  by  properly  adapted  exercises. 

In  regard  to  food  there  is  also  great  improvement,  but  it  is  too 
often  necessary  to  inculcate  the  importance  of  taking  a  proper  amount 
of  good,  wholesome  nutriment.  Many  girls  have  a  loathing  for  food 
in  the  morning,  and  will,  if  allowed  to  do  so,  go  to  school  with  an 
empty  stomach,  and  let  their  brain  work  for  hours  before  they  take 
any  substantial  food.  A  very  bad  habit,  that  spoils  the  appetite,  causes 
a  sour  stomach,  and  in  consequence  impoverishes  the  blood  and  gives 
rise  to  nervous  troubles,  is  the  immoderate  use  of  candy,  which  among 
women  and  children  corresponds  to  alcoholic  beverages  and  tobacco  in 
men. 

A  fruitful  source  of  disease  among  women  is  the  lack  of  attention 
to  the  excretions.  The  vast  majority  of  gynecological  patients  suffer 
from  constipation.  They  will  go  for  days — nay,  sometimes  a  whole 
week — without  a  movement  of  the  bowels.  This  accumulation  of 
feces  gives  rise  to  local  trouble  by  pushing  the  uterus  out  of  its  place 
and  interfering  with  the  free  circulation  of  the  blood  in  the  pelvis ; 
but,  besides,  it  causes  absorption  of  the  gaseous  and  liquid  part  of  the 
fecal  material,  that  shows  its  deleterious  effect  in  bloodless  lips, 
headache,  neuralgia,  and  fatigue.  The  excretion  of  the  urine  is  no 
less  neglected.  The  requirements  of  polite  society  will  often  prevent 
women  from  emptying  the  bladder  in  time,  which  may  lead  to 
paralysis  of  that  organ,  not  to  speak  of  rupture,  and  not  uufrequently 
is  the  cause  of  cystitis  and  neuralgic  pain,  besides  predisposing  to 
uterine  disease  by  pushing  the  womb  out  of  place. 

The  mode  of  dressing,  although  changing  under  the  varying  caprices 
of  fashion,  is  always  fundamentally  wrong  and  conducive  to  disease. 
The  "  decollete" "  evening  dress  and  the  bell-shaped  nether  garments 
drive  the  blood  from  the  periphery  to  the  pelvis.  The  lower  part 
of  the  abdomen  is  generally  insufficiently  protected  from  cold  air  and 
blasts  of  wind,  which  become  particularly  dangerous  to  women  who 
skate.  High  heels,  when  worn  at  an  early  age,  while  all  articulations 
are  yet  subject  to  change,  not  only  alter  the  shape  of  the  foot,  but  are 
apt  to  cause  neuralgia  in  the  legs  and  a  change  in  the  inclination  of 
the  pelvis  and  the  normal  curvature  of  the  back.1 

1  S.  Busey,  Trans.  Amer.  Oyn.  Soc.,  1882,  vol.  vii.  pp.  243-261. 


ETIOLOGY  IN  GENERAL.  129 

Of  much  greater  importance  yet  is  the  use  of  corsets.  Even  a  loose 
corset  exercises  a  pressure  of  30  pounds,  which  has  still  greater  effect 
on  the  abdominal  cavity  than  on  the  thoracic.  The  abdominal  wall 
is  thinned  and  weakened.  In  the  erect  posture  the  liver  and  intes- 
tines are  pushed  forward,  driving  the  weakened  abdominal  wall  in 
front  of  them,  and  in  sitting  the  normal  pressure  backward  from  the 
abdominal  wall  against  the  spinal  column  is  changed  into  one  going 
directly  down  into  the  pelvic  cavity.  By  tight  lacing  the  pelvic 
flk*>r  is  bulged  down  to  the  extent  of  one-third  of  an  inch.1 

Late  hours,  social  gatherings  beginning  at  the  time  when  the  girl 
ought  to  go  to  bed,  have  a  very  bad  effect  on  the  nervous  system,  and 
predispose  to  much  greater  suffering  from  actual  trouble  than  is  felt 
by  those  leading  a  more  natural  life. 

Neglect  during  menstruation  seems  to  be  a  fruitful  source  of  female 
complaints.  Women  not  only  move  about,  but  dance  and  skate,  at  a 
time  when  a  process  is  going  on  that  is  so  easily  turned  in  an  abnor- 
mal direction. 

We  have  seen  in  the  chapter  on  Physiology  how  differently  women 
are  constructed  from  men  in  regard  to  sexual  excitement.  It  is 
very  unlikely  that  the  mere  frequency  of  normal  sexual  intercourse 
does  a  healthy  woman  any  harm,  but  it  is  quite  different  when  the 
natural  relations  are  disturbed.  The  sin  of  Onan,2  sodomy,  and  even 
the  use  of  condoms,  injections  made  in  a  hurry  immediately  after 
ejaculation  at  a  moment  when  nature  calls  for  rest,  and  often  with  a 
fluid  of  improper  temperature,  all  cause  a  tension  of  the  nervous  system 
and  a  congestion  of  the  genitals  which  in  the  course  of  time  result  in 
hemorrhage,  leucorrhea,  chronic  metritis,  fibroids,  or  other  affections. 

Marriage  with  existing  disease  of  the  pelvic  organs  often  lays  the 
foundation  of  much  wretchedness  for  both  husband  and  wife.  If  a 
flexion  of  the  uterus  may  be  cured  by  childbirth,  provided  conception 
takes  place  in  spite  of  it,  how  different  is  it  when  the  ovaries  or  tubes 
are  the  seat  of  chronic  inflammation,  which  causes  excruciating  pain 
at  the  mere  touch  during  a  careful  examination  ! 

If  married  life  has  its  dangers,  celibacy  does  not  offer  entire  pro- 
tection. Especially  is  the  liability  to  the  formation  of  fibromas  of 
the  uterus  greater  in  unmarried  and  nulliparous  women  than  in  those; 
who  have  borne  children,  as  if  the  uterus,  deprived  of  the  function 
of  building  up  a  new  being,  were  more  liable  to  use  the  material  for 
the  formation  of  a  tumor. 

1  The  question  of  the  effect  of  the  corset  and  other  wearing  apparel  has  been  ably 
discussed  by  Dr.  Eobert  L.  Dickinson  in  the  New  York  Med.  Jour.,  Nov.  5,  1 887, 
Hare's  System  of  Therapeutics,  vol.  iii.  pp.  730-784,  and  Trans.  Amer.  Gyn.  Soc.,  1893, 
vol.  xviii.  pp.  411-433. 

2  A  careful  perusal  of  Genesis  xxxviii.  9  will  convince  the  render  that  thereby  is 
not  meant  the  vice  which  erroneously  has  been  named  after  that  man,  and  which 
properly  is  called  masturbation,  but  the  practice  commonly  known  as  "  withdrawal." 


130  DISEASES  OF  WOMEN. 

In  married  as  well  as  unmarried  women  the  climacteric  predisposes 
to  disease — a  point  which  has  been  considered  in  a  previous  chapter 
(p.  124). 

Exciting  Causes. — Sometimes  a  faulty  development  of  the  fetus 
constitutes  directly  a  disease.  Too  great  closure  of  the  two  halves 
forming  the  body  gives  rise  to  atresia ;  too  little  results  in  hypospa- 
dias,  epispadias,  or  extroversion  of  the  bladder.  Arrest  of  develop- 
ment may  also  cause  an  infantile  uterus.  The  genitals  may  be  more 
or  less  completely  absent.  These  conditions  will  be  discussed  under 
the  diseases  of  the  special  organs. 

Coition  during  menstruation  has  often  been  the  cause  of  retro-uterine 
hematocele. 

Childbirth  is  a  fruitful  source  of  disease  to  women,  sometimes  with- 
out, but  oftener  with,  fault  on  the  part  of  the  obstetrician.  Tears  of 
the  vaginal  entrance  often  lay  the  foundation  of  prolapse  of  the  vagina 
or  the  uterus.  A  torn  cervix  gives  rise  to  ectropion  of  the  mucous 
membrane,  leucorrhea,  hemorrhage,  cystic  degeneration  of  the  cervix, 
secondary  sterility,  neuralgia,  impaired  nutrition,  and  carcinoma  or 
sarcoma  of  the  uterus.  Too  early  rising  after  confinement,  while  the 
uterus  is  still  large  and  soft,  often  causes  subinvolution  or  displace- 
ment of  that  organ.1  Through  deficient  antiseptic  precautions  inflam- 
mation is  started  in  the  uterus,  the  tubes,  the  connective  tissue  of  the 
pelvis,  or  the  peritoneum — conditions  which,  if  they  do  not  end  the 
patient's  life  at  once,  often  leave  her  sterile  or  a  sufferer  for  life. 

Abortions,  spontaneous  or  legitimately  induced  to  avert  greater 
evil,  may  give  rise  to  conditions  calling  for  the  gynecologist's  inter- 
ference ;  but  of  by  far  greater  importance  is  the  criminal  abortion  so 
frequently  resorted  to  by  women  in  all  classes  of  society,  in  the  coun- 
try as  well  as  in  cities.  Sometimes  the  ignorance  and  recklessness 
of  the  abortionist  go  so  far  that  he  makes  a  hole  in  the  uterus  through 
which  one  can  put  one's  thumb,  and  through  which  the  intestines 
may  find  their  way  into  the  vagina  and  down  between  the  thighs;2 
and  it  is  by  no  means  rare  to  read  in  the  reports  of  coroners'  autopsies 
in  suits  for  malpractice  that  wounds  inflicted  with  some  sharp  or 
pointed  instrument  are  found  in  the  genitals  of  those  who  have  suc- 
cumbed in  consequence  of  criminal  abortion.  But,  even  apart  from 
these  surgical  injuries,  there  are  two  immediate  dangers  of  abortion — 
namely,  hemorrhage  and  septicemia,  which  are  due  to  retention  of 
the  whole  or  part  of  the  ovum.  Hemorrhage  occurs  in  two  forms : 
either  in  the  shape  of  sudden  considerable  flooding  or  as  a  constant 
or  frequently-repeated  loss  of  small  amounts  of  blood,  which  is  due 

1  This  question  has  been  considered  at  length  in  my  article  "  Rest  after  Delivery," 
Amer.  Jour.  Obstetrics,  vol.  xiii.  No.  iv.  Oct.,  1880,  pp.  851-863. 

2  Cases  of  this  kind  were  reported  by  Thomas  and  Noeggerath  in  the  Obstetrical 
Society  of  New  York,  Amer.  Jour.  Obstet.,  1882  (Supplement,  pp.  4-6). 


ETIOLOGY  IN  GENERAL.  131 

to  fungosities  of  the  endometrium,  and  undermines  the  most,  robust 
constitution. 

The  more  remote  effects  of  abortion  are  similar  to  those  of  too  early 
rising  after  childbirth,  especially  subinvolutious  and  displacements.1 

Gynecological  Treatment. — Unfortunately,  our  list  of  the  chief 
direct  causes  of  gynecological  diseases  would  be  incomplete,  if  we  left 
out  the  gynecological  treatment  itself.  Even  with  the  greatest  care, 
our  procedures  are  frequently  not  free  from  danger,  and,  if  we  ne- 
glect antiseptic  precautions,  the  danger  increases  manifoldly.  Espe- 
cially is  all  intra-uteriue  treatment  with  sounds,  curettes,  tents,  dilators, 
and  pessaries 2  fraught  with  danger  on  account  of  the  absorption  of 
septic  material,  which  so  easily  takes  place  through  the  lymphatics" 
of  the  endometrium. 

Gonorrhea. — Greater  than  any  other  danger  is,  however,  sexual 
intercourse  with  a  man  who  has  gonorrhea,  or  who  has,  perhaps,  had 
one  many  years  ago  which  has  not  been  thoroughly  cured.  While  a 
gonorrhea  in  man  in  most  cases  is  a  trifling  disorder,  although  excep- 
tions, iu  which  it  leaves  a  serious  condition,  and  even  becomes  fatal, 
are  not  so  very  rare,  in  women  it  is  one  of  the  most  serious  diseases. 
If  it  only  aifects  the  vagina  and  the  urethra,  it  is  of  less  consequence. 
It  is  already  more  serious  if  it  extends  into  the  vulvo-vaginal  glands, 
but  if  it  works  its  way  up  through  the  uterus  to  the  tubes,  ovaries, 
and  pelvic  peritoneum,  it  jeopardizes  not  only  the  woman's  life,  but, 
if  she  survives,  she  is  most  frequently  left  sterile,  and  is  often  an 
invalid  for  life,  being  subject  to  a  chronic  inflammation  of  the  tubes 
and  ovaries,  with  frequent  acute  attacks  of  peritonitis  and  an  incur- 
able uterine  catarrh  due  to  reinfection  from  the  tubes.  If  sterility 
•does  not  follow,  such  women  often  have  an  attack  of  puerperal  endo- 
raetritis  in  every  confinement. 

Under  the  name  of  latent  gonorrhea  has  been  described  a  condition 
in  which  a  woman  is  infected  by  a  man  who  had  a  gonorrhea  months 
or  years  before.  No  acute  gonorrhea  is  produced,  but  the  women 
become  ailing,  remain  sterile,  and  are  affected  with  chronic,  subacute, 
sometimes  acute,  very  often  relapsing,  inflammation  of  the  internal 
genitals.3 

1  An  interesting  paper  on  "  Abortion  and  its  Effects  "  was  read  by  Dr.  J.  T.  John- 
son of  Washington,  D.  C.,  before  the  Medical  and  Chirurgical  State  Faculty  of 
Maryland,  on  April  23,  1890  (Maryland  Med.  Jour.). 

2Garrigues,  "Danger  of  Stem  Pessaries,"  Amer.  Jour.  Obstet.,  Oct.,  1879,  vol.  xii. 
p.  756. 

3Emil  Noeggerath,  "Latent  Gonorrhea,"  Trans.  Amer.  Gyn.  Soc.,  1876,  vol.  i.  p. 
268,  et  seq. 


PART   V. 

EXAMINATION  IN  GENERAL. 

THE  examination  of  a  gynecological  case  is  verbal  and  physical. 

Verbal  Examination. — The  aim  of  this  work  being  to  offer  a  prac- 
tical guide  for  general  practitioners,  I  shall  not  expatiate  about  all 
that  we  might  be  led  to  surmise  by  a  number  of  symptoms  elicited 
by  a  protracted  conversation — conundrums  that,  anyhow,  only  find 
their  solution  by  a  physical  examination ;  but  I  shall  briefly  state  the 
questions  I  ask  a  patient  before  proceeding  any  further. 

Age. — The  age  ought  to  be  ascertained,  because  it  often  gives  a 
measure  of  the  weakness  or  robustness  of  the  constitution  of  the  pa- 
tient, may  throw  some  light  on  the  nature  of  the  affection  for  which 
she  consults  us,  and  may  give  us  a  hint  in  regard  to  special  epochs  in 
her  life,  such  as  puberty  or  the  climacteric. 

Social  Position  and  Pursuits. — It  is  useful  to  know  whether  we 
have  to  do  with  a  society  lady,  whose  greatest  fatigue  is  her  social 
obligations;  a  shop-girl,  who  is  kept  standing  or  tripping  about  all 
day  long ;  or  a  washerwoman,  who  stands  bent  over  the  tub  rubbing 
linen  day  after  day.  It  is  of  importance  to  know  whether  the  patient 
spends  her  day  in  studying  or  in  artistic  pursuits — conditions  which, 
as  a  rule,  are  combined  with  a  highly-developed  but  over-sensitive 
nervous  system.  It  is  necessary  to  know  something  about  the  finan- 
cial resources  of  the  patient.  In  the  poor  recourse  to  more  radical 
measures  is  often  imperative,  while  those  who  possess  adequate  means 
may  be  benefited  by  a  less  vigorous  but  more  protracted  treatment. 

Duration  of  Sickness. — The  knowledge  of  the  length  of  time  during 
which  the  patient  has  been  sick  teaches  us  at  once  whether  we  have 
to  deal  with  an  acute  or  a  chronic  disease. 

Condition. — It  is  of  the  very  greatest  importance  to  know  whether 
our  patient  is  single,  married,  or  a  widow,  or  has  sexual  connection 
without  being  married.  If  she  is  married,  we  want  to  know  how 
long  she  has  been  so. 

Childbirth  and  Miscarriages. — Next  we  want  to  know  how  many 
children  she  has  borne,  the  age  of  the  oldest  and  the  youngest,  and  if 
she  has  had  any  miscarriages.  A  rapid  succession  of  pregnancies  is 
in  many  cases  an  important  etiological  point.  Often  the  disease  for 
which  we  are  consulted  may  be  referred  to  the  last  confinement.  If 

132 


EXAMINATION  IN  GENERAL.  133 

she  is  sterile,  we  must  find  out  if  it  is  a  natural  condition  or  due  to 
the  use  of  preventives.  If  we  find  sterility  combined  with  dysmen- 
orrhea,  we  nearly  always  find  a  flexion  of  the  womb,  and  most  fre- 
quently an  auteflexion,  often  combined  with  a  narrow  os.  If  there 
have  been  many  miscarriages,  we  must  ask  if  they  were  spontaneous 
or  induced.  If  criminal  abortion  has  been  performed,  that  gives  often 
the  clue  to  the  origin  of  the  disease,  while,  on  the  other  hand,  repeated 
spontaneous  miscarriages  generally  are  due  to  a  misplacement  of  the 
uterus  or  to  syphilis,  either  in  the  patient  or  her  husband,  or  both. 

Menstruation. — The  normal  period  is  twenty-eight  days,  of  which 
menstruation  lasts  four  (p.  115).  Some  women  have  periods  of 
twenty-seven  or  twenty-nine  days;  some  even  of  only  three  weeks. 
The  duration  varies  likewise  a  good  deal  within  normal  limits.  Some 
women  menstruate  only  a  day  or  two,  others  for  a  whole  week  ;  but, 
as  a  rule,  such  conditions  are  allied  to  symptoms  which  show  that  we 
have  to  do  with  something  abnormal.  The  amount  of  blood  lost  at 
the  menstrual  period  is  of  greater  importance  than  its  duration,  since 
one  will  lose  more  in  a  day  than  another  in  a  week.  As  a  rule, 
women  are  able  to  tell  whether  they  lose  much  or  little,  even  if  they 
do  not  use  diapers,  the  numbers  of  which  are  often  given  as  measure 
of  the  amount  of  the  discharge.  Normally,  menstruation  is  only 
preceded  and  accompanied  by  a  feeling  of  heaviness,  especially  in  the 
loins.  Menstrual  pain  is  always  a  sign  of  disease.  If  it  precedes  the 
flow  for  many  days,  it  is  probably  of  ovarian  origin,  while  a  pain  felt 
for  a  day  and  relieved  by  the  flow  is  in  most  cases  referable  to  a 
flexion  of  the  uterus,  and  a  pain  continuing  during  menstruation 
points  toward  a  diseased  condition  of  the  endometrium. 

If  menstruation  is  absent,  we  ask  if  it  has  ever  been  established. 
If  it  has  not,  we  must  take  the  patient's  age  into  consideration 
(p.  115)  and  ascertain  if  she  has  molimina — i.  e.  if  at  regular  intervals 
of  four  weeks  she  suffers  from  abdominal  pain,  cerebral  congestion, 
and  general  malaise.  If  the  patient  has  reached  the  age  of  puberty, 
is  otherwise  well  developed,  and  has  monthly  molimina,  a  physical 
examination  is  imperatively  called  for,  in  order  to  find  out  whether 
some  malformation  forms  a  barrier  which  prevents  the  blood  from 
escaping  from  the  genitals.  We  must  inquire  if  the  patient  is  subject 
to  a  regular  bleeding  from  other  parts  which  might  have  the  charac- 
ter of  a  vicarious  menstruation  (Part  VII.,  Chap.  II.). 

If  menstruation  has  been  established,  we  must  ask  if  it  is  the  first 
time  it  has  failed  to  appear,  or  if  similar  periods  of  amenorrhea  have 
preceded.  We  must  ask  if  it  has  been  suddenly  suppressed,  and  if 
any  cause  for  such  suppression  is  known — e.  g.  exposure  to  cold. 

Under  all  circumstances  of  disappearance  of  the  menstrual  flow  the 
physician  must  think  of  the  possibility  of  pregnancy,  and  inquire 
about  nausea  and  vomiting,  and  if  the  patient  is  unmarried,  under 


134  DISEASES  OF  WOMEN, 

some  plausible  pretext,  obtain  an  examination  of  the  breasts,  which 
may  give  such  corroborative  information  that  a  vaginal  examination 
must  be  proposed.  Even  with  married  women  he  must  remember 
that  they  may  be  pregnant  without  knowing  it,  or  may  be  led  by  the 
secret  desire  that  something  may  be  done  that  will  put  an  end  to 
their  pregnancy. 

So-called  menstruation  recurring  a  year  or  more  after  the  meno- 
pause is  very  suspicious,  as  it  generally  is  a  hemorrhage  caused  by 
cancer. 

Discharge. — We  ask  the  patient  if  she  lias  any  discharge  from  the 
genitals  between  her  periods,  and  if  so  what  color,  consistency,  and 
odor  it  has.  A  discharge  is  always  an  abnormality.  A  white,  milky 
discharge  is  of  least  importance;  a  thick,  glairy  one  comes  from  the 
cervix,  and  is  often  hard  to  cure ;  a  bloody  one  comes  probably  from 
ulcers  or  granulations ;  a  purulent  one  is  a  sign  of  a  deeper  inflam- 
mation, which  often  is  of  gonorrheic  origin,  or  it  may  come  from 
ulcers ;  an  offensive  one  is  particularly  found  in  cancer. 

Micturition  and  Defecation. — After  these  questions  about  the  geni- 
tals proper  we  inquire  about  the  condition  of  the  neighboring  organs. 
Very  often  we  find  frequent  or  painful  micturition,  even  without 
disease  of  the  urinary  organs,  and  constipation. 

Pain. — The  symptom  that  most  frequently  brings  the  patient  to 
seek  help  is  pain.  The  pain  has  certain  places  of  predilection,  which, 
according  to  decreasing  frequency,  may  be  arranged  in  the  following 
list :  the  left  iliac  fossa,  the  right  iliac  fossa,  or  both ;  backache,  pain 
under  the  left  breast,  pain  in  the  epigastric  region,  headache,  neuralgia 
on  the  anterior  surface  of  the  thigh  (anterior  crural  nerve),  neuralgia 
on  the  external  surface  of  the  same  (external  cutaneous  nerve),  pain 
in  the  coccygeal  region  or  in  the  interior  of  the  pelvis  when  sitting. 
As  a  rule,  the  pain  is  increased  by  walking  or  other  exertions.  Fre- 
quently coition  is  painful  (dyspareuma).  When  a  pain  is  felt  on 
one  side  of  the  body,  it  is,  as  a  rule,  on  the  affected  side,  but  some- 
times it  is  referred  to  the  opposite  side. 

Worse  than  real  pain  are  sometimes  other  abnormal  sensations, 
such  as  itching  or  burning. 

Sometimes  patients  suffer  from  a  pricking  pain  in  the  eyeballs,  with 
weak  eyesight  (asthenopia),  palpitations,  and  the  different  nervous 
symptoms  known  as  hysteria. 

Nutrition  and  Strength. — Most  frequently  gynecological  patients 
are  thin  and  anemic,  their  appetite  is  poor,  and  they  suffer  from  dys- 
pepsia. They  complain  of  feeling  tired,  and  are  unable  to  do  the 
same  amount  of  work  as  before  they  were  taken  sick. 

Family  History. — Sometimes  the  family  history  helps  to  a  diag- 
nosis, especially  in  regard  to  such  hereditary  diseases  as  tuberculosis 
and  cancer. 


EXAMINATION  IN  GENERAL. 


135 


Special  Question.*. — In  special  cases  many  other  questions  suggest 
themselves.  For  instance,  if  the  patient  has  an  enlarged  abdomen, 
it  is  of  great  importance  to  know  in  what  locality  the  enlargement 
was  first  noticed.  If  during  the  physical  examination  we  find  great 
tenderness  in  a  married  woman,  it  is  a  pertinent  question  to  ask  if 
coition  is  painful,  and,  if  so,  how  often  it  takes  place.  When  there 
is  a  deficient  development  of  the  genitals,  it  is  proper  to  ascertain  if 
the  patient  has  a  normal  sexual  appetite  and  feels  any  normal  satis- 
faction in  sexual  intercourse.  Venereal  affections  call  for  a  close 
examination  in  regard  to  the  time  of  their  first  appearance,  preceding 
or  concomitant  symptoms  (ulcers,  rash,  sore  throat,  alopecia),  and  the 
health  of  the  husband.  Sometimes  it  becomes  necessary  to  ask  the 
patient  if  she  masturbates,  which  usually  can  be  done  by  asking  if 
she  suffers  from  heat  in  the  genitals,  if  she  touches  them,  if  she 
scratches  herself,  and  so  forth.  But  all  such  special  questions  will, 
as  a  rule,  best  be  put  during  or  after  the  physical  examination. 

Physical  Examination. — For  the  physical  examination  we  must 
make  use  of  four  of  our  senses — viz.  sight,  touch,  smell,  and  hearing 
— and  certain  instruments  or  apparatus.  Most  examinations  can  be 
satisfactorily  made  with  the  patient  lying  in  her  bed  or  on  a  lounge, 
and  in  private  practice,  in  the  home  of  the  patient,  most  examinations 
are  made  in  this  way.  Certain  things  are,  however,  felt  much  better, 
or  are  first  brought  out,  when  the  patient  lies  on  an  even,  unyielding 
surface,  and  office  practice  is  much  expedited  by  having  a  couch 
especially  made  for  the  purpose.  There  are  numerous  examining 
chairs  and  tables  in  the  market  and  in  more  or  less  common  use. 
Tables  are  by  far  to  be  preferred  to  chairs,  the  latter  not  allowing  so 
easily  and  so  completely  a  change  from  the  dorsal  to  the  lateral  pos- 
ture. A  common  table  with  a  hard 
mattress  may  be  used,  but  it  is  a 
great  improvement  to  have  a  table 
that  can  easily  be  made  to  slant 
backward,  and  to  that  side  which  is 
to  the  right  of  the  physician  when 
he  stands  at  the  foot  of  the  table 
and  turns  his  face  to  the  patient. 
The  most  perfect  table  is,  I  believe, 
Daggett's,  of  Buffalo,  N.  Y.  (Fig. 
108).  Whatever  table  is  used 
should  be  placed  near  a  window, 
with  the  foot  end  turned  toward  as 
good  a  light  as  can  be  obtained.  Daggett's  Table. 

The  bladder  and  the  rectum  must 

be  empty.     If  the  bladder  is  more  or  less  full,  the  urine  may  be 
drawn  when  the  patient  is  on  the  table.     If  the  rectum  is  loaded,  it 


FIG.  108. 


136 


DISEASES  OF  WOMEN. 


is  better  to  postpone  the  examination  until  the  intestines  have  been 
emptied  by  means  of  an  enema  and  an  aperient.  By  neglecting  these 
precautions  the  beginner  may  fall  into  serious  errors,  such  as  to  dia- 
gnosticate pregnancy  or  tumors  that  are  destined  soon  to  disappear  in 
the  water-closet. 

I.  POSITIONS. — The  two  chief  positions  used  for  examining  a 
gynecological  patient  are  the  dorsal  and  Sims's.  Of  less  importance 
are  the  genu-pectoral,  the  erect,  Trendelenburg's,  and  the  ventral 
positions. 

The  Dorsal  Position. — The  patient  lies  on  her  back,  the  head 
slightly  raised  on  a  cushion,  the  knees  drawn  up  and  widely  sepa- 

FIG.  109. 


Dorsal  Position. 


rated,  and  the  heels  placed  on  the  table  or  in  front  of  it  or  above 
its  foot-end  in  some  kind  of  holes  or  stirrups  (Fig.  109).  The  skirts 
are  pushed  up  on  the  abdomen.  For  a  complete  examination  of  the 
abdomen  the  corset  must  be  removed,  and  all  bands  round  the  waist 
opened,  but  for  an  exploration  of  the  pelvic  cavity  we  need  only 
insist  on  the  removal  of  closed  drawers.  In  this  way  we  save  much 
time  and  cause  the  patient  less  trouble.  When  she  is  in  position,  she 
should  be  covered  up  to  the  breasts  with  a  sheet,  which  thereafter  is 
folded  in  between  her  legs,  so  as  to  leave  only  the  vulva  exposed. 


EXAMINATION  IN  GENERAL. 


137 


the 


If  no   inspection   is   intended,  but  only  a  digital   examination, 
patient  remains  entirely  covered  under  the  sheet. 

The  modification  of  the  dorsal  position  called  breech-back  position 
will  be  described  under  "  Preparation  for  Operations  in  General "  and 
tinder  "  Urinary  Fistula." 

Sims' s  Position  (Fig.  110)  is  a  position  on  the  left  side,  but  by  no 
means  is  every  left-side  position  Sims's  position.  In  the  latter  the 
patient  lies  on  her  left  side  half  turned  over  on  her  front.  The  left 
side  of  the  face  rests  on  a  cushion;  the  left  breast  touches  the  table; 

FIG.  110. 


Sims's  Position. 


the  left  arm  is  placed  behind  the  body ;  and,  if  the  table  is  narrow, 
both  arms  hang  down  beside  it,  but  if  it  is  too  broad,  the  right  fore- 
arm and  hand  may  rest  on  the  cushion  in  front  of  the  face ;  the  nates 
form  an  inclined  plane,  the  right  being  a  little  nearer  the  head  and  in 
front  of  the  left;  the  right  leg  lies  on  the  left,  but  is  drawn  a  little 
higher  up  toward  the  pelvis. 

These  two  positions  should  be  used  in  every  case  at  the  first  exam- 
ination. The  dorsal  position  is  the  best  for  bimanual  examination, 
for  the  use  of  the  plurivalve  speculum,  and  for  the  examination  of 
the  abdomen.  "Sims's  position  allows  us  to  introduce  one  or  two  fin- 
gers much  higher  up  behind  the  uterus  than  when  the  patient  is  in 
the  dorsal  position.  Even  things  in  the  anterior  part  of  the  pelvis 


138 


DISEASES  OF   WOMEN. 


are  sometimes  felt  better ;  for  instance,  au  anteflexion  which  cannot 
be  made  out  while  the  patient  is  on  her  back,  may  become  quite  plain 
when  the  bent  uterus  falls  forward  over  the  tip  of  the  examining 
finger  in  Sims's  position.  The  chief  advantage  of  this  position  is, 
however,  that  it  admits  of  the  use  of  Sims's  speculum,  and  is  prefer- 
able to  others  in  certain  operations. 

The  genu-pectoral  position  is  rarely  used  for  diagnostic  purposes, 
but  is  sometimes  useful  in  replacing  a  retroflexed  gravid  uterus,  or  a 
prolapsed  ovary.  The  patient  rests  on  her  knees,  the  upper  part  of 
the  chest,  the  right  side  of  the  face,  and  the  right  forearm  (Fig.  111). 
The  thighs  are  kept  perpendicular  and  the  back  hollowed. 

The  erect  position  is  useful  in  order  to  ascertain  if  there  is  any  pro- 
lapse of  the  vagina  or  uterus.  The  patient  stands  with  the  feet  about 

FIG.  111. 


Genu-pectoral  Position  (H.  F.  Campbell). 

half  a  yard  apart,  slightly  bent  forward.     The  physician  sits  in  front 
of  her  and  introduces  the  index-finger  into  the  vagina. 

Ti'endelenburg's1  position  (Fig.  112)  is  sometimes  useful  in  deter- 
mining the  connection  between  an  abdominal  tumor  and  the  pelvic 
organs.  The  patient  lies  on  her  back  on  a  strongly  inclined  plane, 
with  much-elevated  pelvis,  and  her  legs  hang  over  a  flap  that  can  be 
raised  from  the  table.  This  position,  which  rarely  is  used  for  diag- 
nostic purposes,  is  of  the  highest  value  in  operations  in  the  depth  of 
the  pelvis.  In  protracted  operations  in  Trendeleu burg's  position  the 
pelvic  organs  become  comparatively  anemic,  and  when  the  patient  is 
brought  back  to  the  horizontal  position,  a  congestion  takes  place,  which 
may  cause  hemorrhage  corresponding  to  what  takes  place  after  the 
artificial  anemia  brought  on  by  Esmarch's  method.  It  is,  therefore, 

1  The  accent  is  on  the  first  syllable:  Tren 'del  en-burg.  This  surgeon  has  called 
particular  attention  to  this  position,  but  it  was  already  described  by  Bardenhener 
(Drainirung  der  Peritonealhohlt,  Stuttgart,  1881,  p.  276),  and  is  said  to  have  been  used 
still  earlier  by  Billroth  in  Vienna, 


EXAMINATION  IN  GENERAL. 


139 


a  wise  precaution  to  raise  the  foot-end  of  the  bed  during  the  first  two 
or  three  hours  after  the  operation.1 

The  ventral  position  is  needed  when  we  want  to  use  percussion  on 
the  lumbar  region ;  e.  (j.  in  a  case  of  supposed  floating  kidney.  The 
patient  lies  stretched  out  on  her  front  surface  and  one  side  of  her  face, 
and  the  physician  stands  at  her  side. 

When  the  patient  is  placed  in  the  proper  position,  we  proceed  to 
examine  her,  and,  in  order  not  to  overlook  anything,  we  will  consider 
separately  the  examination  of  the  pelvis,  the  examination  of  the  abdo- 
men, and  other  diagnostic  means. 

II.  THE  EXAMINATION  OF  THE  PELVIS. — The  means  employed 
are  inspection  ;  digital  examination  through  the  vagina,  the  rectum, 
and  the  bladder;  combined  examination;  artificial  prolapse  of  the 
uterus;  specula;  the  uterine  sound;  the  probe;  and  dilatation  of  the 
cervical  canal. 

A.  Inspection  is  performed  while  the  patient  is  in  the  dorsal  posi- 
tion. Having  in  mind  the  normal  anatomy  of  the  external  genitals 
(pp.  35  to  47),  we  pay  attention  to  every  deviation  from  the  standard. 

FIG.  112. 


Trendelenburg's  Position  (Leopold's  apparatus) :  a,  adjustable  flap ;  b,  supporter ;  c,  wooden 
frame  fastened  with  clamps  to  table. 

B.  Digital  Examination. — The  fingers,  especially  the  two  index- 
fingers,  are  instruments  of  exploration  of  the  very  greatest  value. 
The  touch  can  to  a  great  extent  replace  vision,  and  is  sometimes 
superior  to  it — e.  g.  in  judging  of  the  extent  of  a  cervical  laceration— 

1  H.  C.  Coe,  New  York  Policlinic,  Sept.,  1893. 


140  DISEASES  OF  WOMEN. 

but  a  good  deal  of  practice  is  needed  before  the  limit  of  all  the  possi- 
bilities of  this  sense  are  reached.  Great  care  should  be  taken  to  cul- 
tivate both  index-fingers,  as  it  is  an  immense  advantage  to  feel  equally 
well  with  both.  By  being  able  to  do  so,  we  can  often  avoid  changing 
the  position  in  which  we  find  the  patient,  which  in  private  practice 
often  is  preferable.  Besides,  the  patient  being  in  the  dorsal  position, 
we  feel  best  with  the  homonymous  finger — i.  e.  we  feel  what  is  in  the 
right  side  of  the  pelvis  best  with  the  right  index-finger,  and  what  is 
in  the  left  side  with  the  left  index-finger. 

The  fingers  and  the  hand  are  used  in  several  ways.  The  index- 
finger  may  be  introduced  into  the  vagina,  the  rectum,  or  the  bladder; 
the  fingers  of  the  other  hand  are  used  on  the  abdomen ;  and  dif- 
erent  forms  of  these  explorations  may  be  combined. 

Cleanliness. — It  goes  without  saying  that  the  physician  shall  have 
clean  hands  and  short  nails,  kept  clean  with  brush  and  steel,  but  strict 
asepsis,  which  is  the  absolute  duty  of  the  obstetrician,  is  not  required 
for  common  gynecological  examinations. 

Lubricants. — Before  the  finger  is  introduced  into  the  vagina  it 
ought  to  be  made  slippery  with  some  suitable  lubricant,  such  as 
vaseline,  olive  oil,  or  a  solution  of  soap.  In  rectal  examinations  it  is 
a  good  plan  first  to  fill  the  space  under  the  nail  by  running  it  over 
a  cake  of  soap.  For  vesical  examination  only  the  mildest  lubricants, 
such  as  vaseline  or  olive  oil,  should  be  used. 

Vaginal  Examination. — The  patient  is  in  the  dorsal  position.  The 
physician  stands  in  front  of  her,  observing  her  face,  which  will  often 
give  valuable  information  in  regard  to  tenderness,  pain,  or  sexual 
excitement.  If  the  vulva  does  not  gape,  the  labia  majora  are  sepa- 
rated with  the  thumb  and  index-finger  of  one  hand,  while  the  index- 
finger  of  the  other  is  introduced.  As  a  rule,  only  the  index-finger  is 
use^  in  the  vagina.  It  is  stretched,  the  last  three  fingers  are  bent 
flat  in  against  the  hand,  so  that  one  right  angle  is  formed  at  the 
joints  between  the  metacarpus  and  the  first  phalanges,  and  another 
between  the  first  and  second  row  of  phalanges  The  index-finger, 
again,  forms  a  right  angle  with  the  first  phalanx  of  the  middle 
finger,  and  the  thumb  is  either  extended  so  as  to  form  a  right 
angle  with  the  metacarpal  bone  of  the  index-finger,  or  bent 
against  the  second  phalanx  of  the  middle  finger  (Fig.  113).  In 
exceptional  cases,  and  in  women  with  large  vaginal  entrances,  both 
the  index  and  the  middle  finger  may  be  used  simultaneously  in  the 
vagina,  which  allows  us  to  penetrate  fully  an  inch  deeper,  but  causes 
some  pain.  In  entering  it  is  well  first  to  ascertain  the  condition  of 
the  vaginal  entrance,  especially  the  perineal  body.  In  proceeding 
we  notice  the  condition  of  the  walls  of  the  vagina  in  regard  to- smooth- 
ness, rugosities,  hardness,  adhesions,  cysts,  etc.  Next,  wre  place  the 
tip  of  the  finger  on  the  os,  and  examine  its  size,  shape,  and  direction. 


EXAMINATION  IN  GENERAL. 


141 


We  notice  the  length,  thickness,  shape,  and  consistency  of  the  cervical 
portion.  The  remainder  of  the  vaginal  examination  is  done  much 
better  by  the  bimanual  method  than  by  the  unassisted  finger.  For 
this  purpose  the  physician  places  the  four  fingers  of  the  other  hand 
on  the  hypogastric  region — in  the  middle  for  the  examination  of  the 
uterus,  over  the  right  and  left  iliac  fossa  for  that  of  the  appendages, 
the  broad  ligaments,  the  parametria,  etc. — and  presses  well  down,  so 
as  to  bring  the  organs  within  easier  reach  of  the  finger  in  the  vagina, 
and  at  the  same  time  palpate  them  from  above. 

The  index-finger  is  placed  against  the  anterior  part  of  the  vaginal 
roof,  while  the  fingers  of  the  other  hand  rest  on  the  fundus.  Thus  we 
easily  sweep  over  the  anterior  surface  of  the  uterus.  Next  we  place 
the  inside  finger  against  the  posterior  part  of  the  roof  of  the  vagina, 
the  so-called  cul-de-sac,  and  push  the  fingers  of  the  other  hand  with 
the  tips  turned  downward  and  the  pulp  forward,  far  down  behind 
the  uterus,  which  in  lean  women  allows  us  to  examine  the  whole  pos- 
terior surface  of  that  organ.  After  that  we  place  the  inside  finger  on 
the  left  lateral  part  of  the  vaginal  roof,  and  the  outside  fingers  over 
the  corresponding  iliac  fossa.  By  pushing  the  inside  finger  well 

FIG.  113. 


Combined  Examination  (Schroeder). 

upward  and  backward,  a  little  outside  of  the  edge  of  the  uterus,  we 
are  sometimes  enabled  to  feel  the  ovaries,  the  tubes,  the  sacro-uterine 
ligaments,  cysts  of  the  broad  ligaments,  exudations,  infiltrations,  pel- 
vic abscesses,  etc.  Finally,  we  examine  the  right  side  of  the  pelvis 
in  the  same  way. 


142  DISEASES  OF  WOMEN. 

Rectal  examination  is  best  performed  with  the  patient  in  Sims's 
position.  We  look  for  hemorrhoidal  tumors,  fissures,  mucous  patches, 
chancroids,  etc.  The  physician  stands  behind  the  patient,  and  intro- 
duces his  right  index-finger  as  far  as  it  goes,  which  is  to  the  so-called 
third  sphincter  (p.  87),  and  in  so  doing  pays  attention  to  tumors, 
ulcers,  or  strictures  of  the  intestine  itself,  and  to  the  condition  of  the 
genitals  in  front  and  the  sacro-uterine  ligaments  to  the  sides.  Some- 
times the  uterine  appendages  are  felt  better  from  the  rectum  than 
from  the  vagina.  In  cases  of  abdominal  tumors  this  examination 
ought  never  to  be  neglected,  as  valuable  information  is  often  gained 
thereby  which  cannot  be  obtained  in  any  other  way.  But  in  most 
cases  the  diagnosis  can  be  made  by  the  other  modes  of  examination, 
and  as  this  one  is  particularly  disagreeable  to  physician  and  patient, 
and  much  more  painful  than  a  vaginal  examination  in  a  woman  who 
has  had  sexual  intercourse,  it  is  by  no  means  used  in  every  case. 

A  peculiar  evolution  of  the  rectal  touch  is  Simon's  intestinal  examin- 
ation, by  which  the  four  fingers,  the  whole  hand,  and  even  a  great 
part  of  the  forearm,  are  introduced  through  the  anus,  the  rectum,  the 
sigmoid  flexure,  and  all  the  way  up  to  the  upper  end  of  the  de- 
scending colon.  The  feasibility  of  this  procedure  shows  how  disten- 
sible the  spincter  ani  is,  but  it  is  a  dangerous  manipulation,  which 
has  caused i rupture  of  the  intestine,  and  is  one  of  the  diagnostic  means 
which  formerly,  when  abdominal  surgery  was  yet  in  its  infancy,  was 
of  value,  but  which  has  fallen  into  disuse  since  laparotomy  has  become 
so  harmless  that  we  do  not  hesitate  to  perform  it  for  diagnostic  pur- 
poses. 

Vesical  Examination. — The  urethra  can  easily  be  dilated  by  means 
of  a  set  of  seven  coniform  tubes  with  obturators  (Fig.  114)  vary- 
ing from  1^  to  2f  inches  in  circumference,  until  the  index-finger 
can  be  introduced  into  the  interior  of  the  bladder.  This  procedure 
permits  the  palpation  of  tumors  in  the  bladder  itself  or  between  the 
uterus  and  the  bladder,  facilitates  the  introduction  of  instruments  into 
the  ureters,  and  may  decide  about  the  presence  or  absence  of  the 
internal  genitals  in  a  case  of  atresia  of  the  vagina.  The  patient  is,  of 
course,  anesthetized,  and  occupies  the  dorsal  position.  The  method 
is  valuable,  but,  as  sometimes  it  has  led  to  incurable  incontinence,1  it 
ought  only  to  be  risked  in  cases  in  which  the  information  sought  is 
of  great  importance  and  cannot  be  obtained  in  any  other  way.2  As 
a  rule,  we  can  reach  our  goal  by  means  of  a  catheter  in  the  bladder 
and  a  finger  in  the  vagina  or  the  rectum,  or  both. 

Combined  Examination. — Sometimes  it  is  an  advantage  to  combine 

1  T.  A.  Emmet,  Principles  and  Practice  of  Gynecology,  2d  ed  ,  1880,  p.  732. 

2  I  have,  for  instance,  done  it  successfully  in  an  old  lady  with  a  large  cancer- 
ous mass  situated  on  the  base  of  the  bladder,  so  as  to  preclude  incision  from  the 
vagina. 


EXAMINATION  IN  GENERAL. 


143 


several  of  the  above-mentioned  methods.  Thus,  a  good  mode  of 
examining  the  perinea!  body  is  to  introduce  the  index-finger  into  the 
rectum  and  the  thumb  into  the  vagina  simultaneously.  In  other 
cases  the  middle  finger  is  introduced  into  the  intestine,  the  index- 
finger  into  the  vagina,  while  the  four  fingers  of  the  other  hand 
palpate  through  the  abdominal  wall. 

C.  Artificial  Prolapse  of  the  Uterm,  by  which  this  organ  is  pulled 
down  by  means  of  a  volsella  to  the  entrance  of  the  vagina,  is  much 
practiced  abroad,  and  has  some  advocates  in  this  country.1  The 
method  is  not  without  danger,  as  it  is  liable  to  set  up  an  acute  peri- 
tonitis or  cellulitis  where  there  are  remnants  of  old  similar  affections, 
and  even  endanger  the  integrity  of  the  tubes  or  large  veins  in  the 
broad  ligaments  if,  perhaps,  they  are  bound  by  old  adhesions  which 
escape  our  attention.  It  is  better  not  to  be  too  zealous  a  diagnostician 

Fia.  114. 


Gustav  Simons's  Urethral  Specula :  B  represents  the  largest  size ;  A  is  one  number 
smaller  (Two-thirds  natural  size). 

than  to  risk  making  the  condition  of  the  patient  worse  in  trying  to 
determine  its  precise  character.2 

D.  ^pecula. — In  order  to  see  the  deeper  parts  of  the  canals  leading 
to  the  pelvic  organs  we  have  instruments  called  "  specula,"  which  at 
the  same  time  are  of  great  importance  for  treatment,  since  they  render 
it  possible  to  make  applications  to,  or  perform  operations  on,  the 

1  Howard  Kelly.has  constructed  a  special  kind  of  hook  for  the  purpose  (Amer.  Jour 
Obsfet.,  1891,  vol.  xxiv.  No.  2,  p.  141 ). 

*  For  details  the  reader  is  referred  to  a  paper  by  H.  C.  Coe,  Med.  Record  Aue  (J 
1890,  vol.  xxxviii.  p.  No.  6,  p.  141. 


144  DISEASES  OF   WOMEN. 

parts  exposed.  We  have  vaginal,  cervical,  rectal,  urethral  specula, 
and  the  cystoscope. 

Vaginal  Specula. — Of  these  there  are  a  great  variety,  but  virtually 
they  may  be  reduced  to  three  types :  the  tubuliform,  the  plurivalve, 
and  the  univalve  specula. 

Of  the  tubuliform  specula,  Fergusson's  is  the  one  most  in  use  (Fig. 
115).  It  is  made  of  glass,  covered  with  black  varnish  on  the  outside. 

FIG.  115. 


Fergusson's  Vaginal  Speculum. 

A  layer  of  tin-foil  is  inserted  between  the  glass  and  the  varnish. 
The  proximal  end  has  a  flange  which  serves  as  handle  and  as  check 
in  introducing  the  instrument.  It  is  mostly  used  with  the  patient 
on  her  back.  The  labia  majora  are  separated,  the  most  prominent 
end  is  introduced  through  the  vagina,  pressing  on  the  periueal 
body.  The  anterior  and  posterior  walls  of  the  vagina  shall  be  seen  all 
the  time  touching  one  another  in  a  transverse  line  until  the  vaginal 
portion  with  the  os  takes  their  place.  This  speculum  gives  excellent 
light,  but  is  inferior  in  all  other  respects :  it  pushes  the  uterus  away ; 
it  spreads  out  a  torn  cervix,  so  that  the  tear  may  b.e  overlooked  j1  it 
cannot  be  used  for  the  inspection  of  the  f'ornix  of  the  vagina,  which 
is  often  of  as  much  interest  to  see  as  the  os ;  it  does  not  allow  us  to 
introduce  the  sound  through  it,  unless  we  take  a  very  wide  and  short 
one,  which,  again,  can  only  be  used  where  the  vagina  is  exceptionally 
wide,  and  which  causes  pain ;  and  it  is  hard  to  clean. 

Of  the  plurivalve  specula,  some  modification  of  Cusco's  bivalve — 
e.  g.  Brewer's  speculum  (Fig.  116) — is  most  generally  useful.  A 
good  instrument  of  this  class  should  have  few  blades,  for  the  more 
blades  the  more  folds  of  the  vagina  will  get  in  between  them  and 
obstruct  the  view.  It  should  have  a  rounded  end,  so  as  to  be  intro- 
duced without  causing  pain.  It  should  have  a  very  wide  opening, 
in  order  to  admit  much  light,  and  at  the  same  time  be  narrow  at  the 
vaginal  entrance,  so  as  not  to  cause  too  much  distension  and  pain 
there.  The  blades  should  be  of  the  same  length  :  if  the  anterior  be 

1  The  almost  exclusive  use  of  this  speculum  in  England  accounts  in  a'  great  meas- 
ure for  the  tardiness  with  which  Emmet's  laceration  and  its  cure  by  operation  were 
recognized  there. 


EXAMINATION  IN  GENERAL. 


145 


half  an  inch  shorter  than  the  posterior,  as  in  some  instruments  of 
this  kind,  the  os  cannot  be  seen  if  the  uterus  is  anteverted. 


Fin.  116. 


Brewer's  Speculum. 

The  bivalve  speculum  is  used  to  greatest  advantage  in  the  dorsal 
position.  Before  introducing  it  the  physician  ascertains  by  touch  the 
position  of  the  os,  and  directs  the  instrument,  closed,  in  that  direction 
to  its  full  length  or  till  he  reaches  the  vaginal  portion.  Then  the 
branches  are  separated  by  turning  the  screw,  and  the  instrument 
pushed  a  little  farther  in,  so  as  to  reach  the  fornix  of  the  vagina. 

The  univalve,  or  Sims' s  speculum  (Fig.  117)  is  the  only  one  that 

FIG.  117. 


Sims's  Speculum. 


shows  the  uterus  and  the  anterior  wall  of  the  vagina  in  their  normal 
position  and  relation,  since  all  it  does  is  to  pull  back  the  perineal  body 
and  the  posterior  vaginal  wall.  It  covers  a  smaller  part  of  the  vagina 
than  the  other  two.  It  alone  allows  us  to  combine  touch  with  sight, 
10 


146  DISEASES  OF   WOMEN. 

and  it  is  indispensable  in  the  performance  of  operations  for  conditions 
which  before  its  invention  were  incurable. 

Sims's  speculum  is  most  frequently  used  with  the  patient  in  the 
genu-pectoral  or  in  Sims's  position,  but  it  is  often  also  used  either  on 
the  posterior  or  on  the  anterior  wall  of  the  vagina,  or  on  both  at  the 
same  time,  in  the  dorsal  decubitus.  Generally,  two  Sims's  specula, 
of  different  sizes,  are  combined  in  one  instrument,  but  for  use  on  the 
posterior  wall  of  the  vagina  in  the  dorsal  decubitus  a  single  one,  with 
a  suitable  handle,  is  required. 

Sims's  own  way  of  introducing  his  speculum  was  to  hold  the  han- 
dle with  the  left  hand  and  use  the  thumb  and  index-finger  of  the 
right  hand  as  a  guide  (Fig.  118);  and  where  there  are  folds  or  other 
obstacles  in  the  way,  this  is  the  best  way  of  introducing  it,  the  end 
of  the  finger  being  used  to  push  the  obstacles  aside  and  place  the  end 

FIG.  118. 


Introduction  of  Sims's  Speculum. 


of  the  speculum  behind  the  cervix.  But  in  ordinary  cases  the  physi- 
cian seizes  the  handle  with  the  right  hand,  placing  the  tip  of  the  index- 
finger  at  the  base  of  the  blade  to  be  introduced.  He  stands  behind  the 
patient,  separates  the  labia,  holds  the  speculum  so  that  its  plane  forms 
an  angle  of  45°  with  the  top  of  the  table,  pushes  it  slowly  in  along 
the  posterior  wall  to  the  posterior  cul-de-sac,  and  brings  it  then  over 
on  the  right  side  of  the  coccyx.  After  that  he  performs  a  move- 
Tnent  in  the  direction  of  part  of  a  circle,  by  which  the  perineal  body 
and  the  posterior  vaginal  wall  are  pulled  back.  In  so  doing  he  gives 
the  air  free  access  to  the  vagina,  and  the  viscera,  falling  by  their  own 
weight,  up  against  the  anterior  abdominal  wall  and  the  diaphragm, 
the  air  distends  the  vagina  so  that  it  becomes  more  like  a  hollow 
globe  than  a  cylinder — the  so-called  ballooning.  This1  ballooning 
may,  however,  occur  under  circumstances  in  which  air-pressure  can- 
not be  the  moving  principle.  I  have  often  felt  it  in  examining 


EXAMINATION  IN  GENERAL. 


147 


.patients  in  the  dorsal  position,  and  I  have  felt  an  exactly  similar  dis- 
tension of  the  rectum  when  the  examining  finger  excluded  all  entrance 
of  air.  In  such  cases  the  ballooning  is,  in  my  opinion  due  to  con- 
traction of  muscles  extending  from  the  wall  of  the  cavity  in  question 
to  fixed  points  in  the  surroundings  (p.  43  and  Fig.  55,  p.  58). 

If  the  os  and  posterior  lip  do  not  present  themselves,  they  must  be 
brought  forward  in  some  way,  either  by  pulling  on  the  anterior  lip 
with  a  tenaculum,  or,  since  this  causes  some  pain,  preferably  by  intro- 
ducing the  end  of  a  sound  into  the  os,  if  that  can  be  reached,  or  by 
using  a  depressor  on  the  anterior  wall  of  the  vagina,  such  as  Sims's, 
consisting  of  a  flexible  metal  rod  with  a  loop  at  each  end  (Fig.  119), 

FIG.  119. 


Sims's  Double  Depressor. 


or,  better,  J.  B.  Hunter's,  a  silver-plated  copper  rod  ending  in  a  spoon 
at  each  end  (Fig.  120),  or  my  own,  which  will  presently  be  described. 


FIG.  120. 


Hunter's  Depressor. 

Modifications  of  Sims's  Speculum. — Munde's  speculum  (Fig.  121) 
is  a  Sims's  speculum  to  which  is  added  a  flange  that  holds  the  upper 
nates  out  of  the  way.  Hubbard  W.  MitchelFs  speculum  (Fig.  122)  is 
a  single  Sims's  speculum  with  Munde's  flange  and  wings,  which  give 
a  good  hold  for  the  index-  and  middle  fingers. 

Self-holding  Sims's  Specula. — If  a  man  holds  one  of  these  flanged 
specula  in  his  left  hand,  or  a  common  Sims's  speculum,  requesting 
the  patient  to  lift  the  upper  nates  herself,  and  he  holds  the  depressor 
in  the  right  hand,  he  can  see  well  enough,  but  no  hand  is  left  for 
treatment.  The  consequence  is,  that  he  must  have  an  assistant.  The 
presence  of  a  third  person,  especially  a  female  nurse,  offers  many 
advantages,  but  not  everybody  who  wants  to  use  Sims's  speculum, 
has  sufficient  gynecological  practice  to  make  it  pay  to  keep  one  for 
the  purpose.  A  number  of  instruments  have,  therefore,  been  con- 
structed with  the  aim  of  making  the  assistant  superfluous  by  render- 


148 


DISEASES  OF   WOMEN. 


ing  Sirns's  speculum  self-holding.     The  best  instrument  of  this  class 
is,  in  my  opinion,  that  of  the  late  Dr.  Ehrich  of  Baltimore  (Fig. 
123).     It   is    true,    no   in- 
strument   can   surpass    the  FlG- 122- 
hand     of    an    experienced 
nurse,  but  to  hold   Sims's 
speculum  for  any  length  of 
time   is    very   trying,   and 
Eh  rich's   speculum  is   infi- 
nitely more  useful  than  the 
hand   of  an  assistant  who 
has  not  had  great  practice 
in  holding  it.     It  is  a  sin- 
gle  Sims's   speculum   with 

FIG.  121. 


Mund^'s  Speculum. 


H.  W.  Mitchell's  Speculum. 


flanges  for  both  nates,  fastened  to  a  curved  metal  rod  articulating 
with  a  plate  which  rests  on  the  sacrum,  and  is  kept  in  place 
by  means  of  a  band  going  over  the  patient's  left  shoulder.  If 
sometimes  a  little  help  is  needed,  it  may  be  rendered  by  any  by- 
stander, since  all  that  is  required  is  to  pull  the  curved  rod  a  little 
backward. 

All  these  self-holding  apparatus  are,  however,  bulky,  expensive, 
apt  to  scare  the  patient,  and  take  much  more  time  to  apply  than  a 
common  Sims's  speculum.  In  order  to  have  all  the  advantages  of 


EXAMINATION  IN  GENERAL. 


149 


the  latter  without  being  obliged  to  have  an  assistant  for  a  mere  appli- 
cation,    curetting,     and 

similar  manipulations,  I  Fio.  123.1 

have  had  a  vaginal  de- 
pressor constructed  which 
is  held  with  the  same 
hand  as  the  speculum 
(Fig.  124).2  The  han- 
dle, seen  to  the  left,  is 
held  against  the  middle 
part  of  a  double  Sims 
speculum.  The  other  end 
is  placed  in  front  of  the 
cervical  portion.  The 
bow  in  the  middle  cor- 
responds to  the  vulva 
and  leaves  the  vagina 
unencumbered.  It  is  on 
purpose  that  there  is  no 
connection  between  the 
depressor  and  speculum. 
A  slight  pressure  with 
the  thumb  allows  the 
physician  to  bring  the 
depressor  in  whatever  Ehrich's  speculum. 

FIG.  124. 


Garrigues'  Vaginal  Depressor. 

1  This  figure  represents  the  speculum  so  modified  that  the  vaginal  blade  is  divided 
into  two  lateral  halves,  which  can  be  separated  and  approximated  by  means  of  a 
screw.  It  has  also  a  depressor  for  the  anterior  wall  which  is  fastened  to  the  upper 
flange.  This  depressor  prevents  one  from  pulling  the  uterus  down  and  has  not  ap- 
peared practical  to  me. 

2  H.  J.  Garrigues,  "A  Vaginal  Depressor,"  Med.  Record,  1881,  vol.  xx.  p.  698. 


150 


DISEASES  OF  WOMEN. 


direction  may  be  needed  for  the  inspection  of  any  irregularly  placed 
os,  and  the  instrument  is  easy  to  cleanse. 

All  specula  are  smeared  with  a  similar  lubricant  as  the  one  used 
for  the  examining  finger  (p.  140).  When  the  cervix  is  exposed  it  is 
in  most  cases  necessary  to  wipe  away  the  mucus  that  covers  it,  which 


FIG.  125. 


Bozeman's  Dressing  Forceps. 


is  done  by  means  of  a  long  pair  of  dressing-forceps  (Fig.  125)  holding 
a  pledget  of  absorbent  cotton  dipped  in  some  antiseptic  fluid. 

Cervical  specula  (Fig.  126)  are  conical  or  cylindrical  tubes  on  a 
long  shaft  which  are  pushed  into  the  cervical  canal.  They  are  less 
used  for  seeing  than  for  preventing  any  application  destined  for  the 


FIG.  126. 


Burrage's  Cervical  Speculum :  a,  tube ;  b,  handle ;  c,  movable  clasp,  preventing  ends  of  wire 
composing  handle  from  slipping  out  of  d,  small  tube  at  right  angles  to  main  tube ;  e, 
smaller  cervical  tube  to  replace  a;  /,  obturator  titling  the  two  tubes. 

cavity  of  the  uterus  from  being  rubbed  off  on  the  cervical  wall,  and 
for  packing  the  uterine  cavity  with  gauze. 

Rectal  specula  cause  much  pain,  and  should  therefore  not  be  used 
unless  imperatively  needed  for  diagnosis  or  treatment.  Often  a  Sims 
or  bivalve  vaginal  speculum  may  be  used  instead  of  a  special  rectal 
speculum.  Ashton's  rectal  speculum  is  constructed  on  the  same  prin- 
ciples a.s  Fergussou's  vaginal,  but  with  a  closed  round  end  and  fenestra 
on  the  side  (Fig.  127).  Kelsey's  bivalve  rectal  speculum  is  the  best 
I  know  of  (Fig.  128). 

Urdhral  specula  are  sometimes  needed.  Jackson's  (Fig.  129)  con- 
sists of  a  tapering  glass  tube,  closed  at  one  end  and  provided  with  a 


EXAMINATION  IN  GENERAL. 
FIG.  127. 


151 


Ashton's  Rectal  Speculum. 


flange  at  the  other,  and  having  a  fenestra  on  one  side.     It  is  conve- 
nient to  have  a  set  of  three  such  tubes,  but  the  one  two  and  a  half 


Fia.  128. 


Kelsey's  Rectal  Speculum. 


inches  long  and  half  an  inch  in  outside  diameter  will  be  suitable  for 
most  cases.1      Skene  has   adapted  Folsom's  nasal  speculum  to  the 


FIG.  129. 


Jackson's  Urethra!  Speculum. 


urethra  (Fig.  130).     It  consists  essentially  of  two  oblong  eyes  of 
1  A.  Reeves  Jackson,  Amer.  Gyn.  Trans.,  1877,  vol.  ii.  p.  575. 


COLLIE 


152 


DISEASES  OF  WOMEN. 


metal  wire  separated  by  spring  force,  and  capable  of  being  kept  at  the 
desired  distance  by  means  of  a  set-screw.     For  the  inspection  of  the 
deeper  parts  of  the  urethra  reflected  light  is 
FIG.  130.  necessary. 

Oystoscope. — By  the  introduction  of  a  minute 
electric  lamp  into  the  bladder  Nitze  and  Leiter 
have  made  this  hidden  cavity  as  distinctly  visi- 
ble as  the  glottis  illuminated  by  the  laryngo- 
scope.1 

E.  The  Uterine  Sound  (Fig.  131)  consists  of 
a  somewhat  flexible  silver-plated  copper  rod 
with  a  flat  handle.  At  the  end  it  has  a  little 
knob,  at  2|  inches  a  small  protuberance  with 
a  notch  marking  the  normal  depth  of  the  ute- 
rine cavity,  and  other  notches  with  figures  by 
which  the  deptli  to  which  the  sound  enters  is 
easily  read  off. 

The  sound  is  a  very  useful,  and,  when  properly  used,  harmless, 
instrument,  but  in  handling  it  we  must  never  forget  that  it  is  a  metal 

FIG.  131. 


Folsom  -  Skene's  Urethral 
Speculum. 


Simpson's  Uterine  Sound. 

rod  hard  enough  to  perforate  the  wall  of  the  womb,  and  that  it  is 
introduced  into  a  cavity  from  which  absorption  easily  takes  place. 
The  greatest  gentleness  of  manipulation  and  antiseptic  precautions  are 
therefore  indicated.  As  to  the  latter,  it  is  hardly  feasible  to  carry 
them  out  strictly  in  every  case,  but  we  ought  at  least  to  disinfect  the 
sound,  and,  if  there  is  any  bad  discharge  in  the  vagina,  it  ought  to 
be  removed  by  an  injection  and  swabbing  before  the  sound  is  intro- 
duced. By  the  use  of  the  sound  pathogenic  germs  may  be  brought 
from  the  vagina,  where  they  abound,  or  from  the  cervix,  where  they 
often  are  found,  into  the  cavity  of  the  corpus,  which  never  is  their 
normal  habitat.  But  in  order  that  the  reader  may  not  form  an  exag- 
gerated idea  of  the  danger  of  this  mode  of  infection,  I  may  state  that 
with  a  very  free  use  of  the  sound,  and  that  for  many  years,  before 
I  used  any  antiseptic  precautions,  I  have  only  four  times  seen  inflam- 
mation occur-; — once  acute  metritis,  and  in  the  other  cases  exudative 
peritonitis. 

The  sound  is  commonly  used  in  the  dorsal  or  in  the  lateral  posi- 

1  Willy  Meyer,  "On  Cystoscopy,"  New  York  Med.  Jour.,  Apr.  21,  1888. 


EXAMINATION  IN  GENERAL.  153 

tion,  with  or  without  speculum.  As  a  rule,  I  think  the  introduction 
in  the  left  lateral  position  without  speculum  is  the  best.  The  sound 
should  never  be  used  before  the  position  and  the  shape  of  the  uterus 
have  been  ascertained  by  palpation,  and  if  there  is  any  marked  devia- 
tion from  the  normal  direction  of  the  uterine  canal,  the  sound  should 
be  curved  so  as  to  correspond  to  it,  apart  from  the  slight  curve  which 
always  is  given  to  the  last  2|  inches  in  order  to  introduce  it  more 
easily  into  the  canal,  which  forms  an  angle  with  the  vagina  (p.  53). 
The  tip  of  the  left  index-finger  is  applied  to  the  os ;  the  lubricated 
or  wet  sound,  held  between  the  thumb  and  index-finger  of  the  right 
hand,  is  slid  along  the  palmar  surface  of  the  finger  till  it  reaches  the  os; 
then  the  finger  is  placed  on  the  front  or  back  of  the  uterus  and  used 
to  tilt  that  organ  in  the  proper  direction  in  order  to  facilitate  the 
introduction  of  the  sound.  A  peculiar  snap  is  felt  when  the  sound 
passes  the  internal  os.  Often  it  is  caught  in  the  folds  of  the  cervix 
(p.  49) ;  then  it  must  be  pulled  a  little  back,  and  turned  in  another 
direction.  When  once  it  has  passed  the  internal  os,  the  handle  is 
pushed  well  back  until  the  stem  points  in  the  direction  of  the  umbili- 
cus. As  soon  as  the  resistance  of  the  fund  us  is  felt  we  desist  from 
further  pushing. 

In  cases  of  anteflexion  the  introduction  is  often  greatly  facilitated 
by  introducing  the  sound  with  the  concavity  turned  backward  as  far 
as  it  goes,  and  then  reversing  it,  or  by  giving  it  a  sharp  curve  near 
the  end  like  a  prostate  catheter. 

In  order  to  measure  the  depth  of  the  uterus,  the  handle  of  the  sound 
is  held  with  the  left  thumb  and  index-finger,  the  tip  of  the  right 
index-finger  is  applied  to  the  sound  just  below  the  anterior  lip,  the 
sound  is  grasped  with  the  right  hand  and  withdrawn,  and  finally 
the  distance  from  the  tip  of  the  finger  to  the  end  of  the  sound  is 
read  off. 

Often  the  sound  is  used  in  connection  with  a  finger  in  the  vagina  or 
in  the  rectum,  or  fingers  pressed  down  behind  the  symphysis  in  order 
to  locate  tumors  in  the  wall  or  in  the  neighborhood  of  the  uterus ; 
and  sometimes  it  is  used  for  moving  the  uterus  in  different  directions, 
and  thus  ascertaining  the  relation  of  this  organ  to  tumors  in  its 
vicinity. 

F.  The  Probe. — The  probe  is  a  much  thinner,  very  flexible  rod 
with  handle,  used  exclusively  for  exploring  the  inside  of  the  uterine 
cavity.     It  is  made  of  metal,  hard  rubber,  or  whalebone. 

G.  The  Curette. — The  curette  is  an  instrument  used  for  scraping 
something  off  the  inside  of  the  uterus.     It  is  mostly  used  as  a  thera- 
peutic agent,  but  sometimes  it  is  employed  in  the  service  of  diagnosis 
in  order  to  obtain  a  specimen  for  microscopical  examination.     The 
chief  curettes  are  Sims's  (Fig.  132)  and  Simon's  (Fig.  133)  sharp 
and  stiff,  and  Thomas's  dull  and  flexible  curettes  (Fig.  134).     In 


154 


DISEASES  OF   WOMEN. 


the  choice  of  a  Thomas  dull  wire  curette  the  purchaser  should  take 
good  care  not  to  buy  one  that  is  so  flexible  that  it  bends  while  being 


FIG.  132. 


Sims's  Sharp  Curette. 


used.     It  should  only  be  so  flexible  that  it  can  be  bent  to  adapt  itself 
to  the  shape  of  the  uterus  in  which  it  is  going  to  be  used.     Simon's 

FIG.  133. 


Simon's  Sharp  Curette. 


seems  to  me  the  best  instrument  for  the  cervix,  and  of  late  years  I 
use  it  also  more  and  more  in  the  body  of  the  uterus.     In  curetting 


FIG.  134. 


Thomas's  Dull  Wire  Curette. 

great  care  should  be  taken  to  disinfect  the  instrument,  the  vagina, 
and  the  interior  of  the  womb  both  before  and  after  operating. 

H.  Dilatation. — Sometimes  it  becomes  necessary  for  diagnostic 
purposes  to  dilate  the  cervical  canal  sufficiently  to  introduce  the 
curette  or  the  finger.  This  may  be  done  slowly  by  means  of  tents,  or 
rapidly  by  means  of  cones  or  diverging  rods  working  on  the  principle 
of  a  glove-stretcher. 

Tents  are  cones  made  of  substances  that  swell  by  absorption  of 
fluid,  especially  sponges,  sea-tangle  (laminaria),  tupelo  root,  and  slip- 
pery-elm bark.  It  is  next  to  impossible  to  get  these  tents  disinfected, 
and  they  are  therefore  dangerous,  and  ought  only  to  be  used  in  very 
exceptional  cases,  especially  for  the  dilatation  of  fistulous  tracts. 

Laminaria  tents  are  disinfected  by  placing  them  for  one  or  two 
minutes  in  boiling  antiseptic  fluid.  This  makes  them,  at  the  same 
time,  so  soft  that  they  can  be  curved  to  fit  a  bent  cervical  canal,  and, 
on  being  placed  in  cold  fluid,  they  become  immediately  hard  again. 
Still,  they  should  never  be  brought  in  contact  with  a  fresh  wound. 
If  the  sound  is  used  and  a  drop  of  blood  appears,  the  introduction 
of  the  tent  should  be  postponed  for  twenty-four  hours.  The  patient 
must  keep  absolutely  quiet  for  a  few  hours  until  the  tent  is  suffi- 


EXAMINATION  IN  GENERAL. 


155 


ciently  swollen  to  be  retained.  The  labor-like  pain  produced  by  the 
swelling  may  be  relieved  by  applying  a  hot-water  bag,  cloths  wrung 
out  of  hot  water,  or  a  hot  poultice  to  the  abdomen.  Jf  needed,  four 
or  more  tents  may  be  introduced,  one  after  the  other,  changing  them 
twice  in  twenty-four  hours,  and  washing  out  the  uterus  at  the  same 
time.1 

The  tent  is  introduced  with  a  pair  of  dressing  forceps  or  Barnes's 
tent-carrier  (Fig.  135). 

For  diagnostic  purposes,  and  as  part  of  treatment,  dilatation  is 

FIG.  135. 


Barnes's  Tent-Introducer.    A  tent  is  seen  fitted  to  the  end  ready  for  introduction.    When  it 
has  been  placed,  the  stylet  on  which  it  is  mounted  is  withdrawn  through  the  larger  tube, 
with  which  the  tent  is  steadied  till  the  stylet  is  quite  free  from  the  tent. 

much  safer  when  performed  rapidly.     For  the  lower  degrees  of  dila- 
tation a  few  of  Hanks's  coniform  hard-rubber  dilators  (Fig.  136)  are 

FIG.  136. 


Hanks's  Uterine  Dilator. 


very  serviceable.  Where  there  is  great  narrowness  of  the  os,  it  may, 
however,  become  necessary  first  to  make  a  small  incision  in  its  edge. 
For  the  next  degree  of  dilatation,  up  tol^  inches,  a  strong  instrument 
of  the  diverging  kind  is  required.  I  have  had  one  made  which  I 


FIG.  137. 


Garrigues'  Uterine  Dilator. 

think  unites  the  best  features  of  the  different  instruments  of  this  class 
(Fig.  137).     It  has  Ellinger's  parallellogram ;  only  one  handle,  in 

1  This  is  the  method  of  B.  S.  Schultze,   Centralblatt  fiir  Gyndkol.,  1878,  vol.  ii. 
p.  150. 


156  DISEASES  OF  WOMEN. 

order  not  to  lose  light ;  fine  ridges  on  the  lower  part  of  the  branches, 
in  order  to  prevent  the  instrument  from  slipping  without  bruising 
the  uterus  too  much ;  curved  branches,  since  these  are  more  easily 
introduced  than  the  straight,  and  the  uteri  upon  which  they  are  used, 
are  commonly  ante-  or  retroflexed.  For  the  very  highest  degrees  of 
dilatation — which,  however,  scarcely  are  needed  for  mere  diagnosis — 
another  set  of  instruments  originated  by  Hanks  for  the  treatment  of 
abortion  are  excellent.  They  consist  of  a  set  of  oblong  balls  of 
hard  rubber  screwed  on  each  end  of  a  curved  shaft  of  the  same 
material.  One  of  the  balls  serves  as  a  handle  while  the  other  is 
being  slowly  pressed  through  the  cervix,  the  lips  of  which  are  in 
the  beginning  pulled  gently  over  the  ball ;  but  later  on  pressure  alone 
is  used  to  propel  the  same  through  the  internal  os.  Filling  out  the 
gap  between  these  two  sets  of  dilators,  the  author  has  had  a  series  of 
ten  hard-rubber  olives  made,  which  can  be  screwed  on  a  metal  shaft. 

Since  dilatation  cannot  be  resorted  to  without  bruising  and  tearing 
the  tissues  to  some  extent,  it  goes  without  saying  that  the  rules  of 
antiseptic  surgery  must  be  scrupulously  observed. 

Dilatation  has  been  carried  to  such  an  extent  as  to  make  the  whole 
cavity  of  the  uterus  visible  up  to  the  fundus  (Vulliet's  method  *). 
This  is  obtained  by  introducing  small  bulbs  of  absorbent  cotton  im- 
pregnated with  iodoform  ether  (1  part  iodoform  to  from  10  to  30 
ether),  dried,  and  tied  to  strings.  These  balls  are  carried  with 
dressing-forceps  and  sound  right  up  to  the  fundus.  Local  anesthesia 
is  produced  with  pledgets  dipped  in  cocaine  solution.  The  patient  is 
in  the  genu-pectoral  posture.  If  the  cervical  canal  is  too  narrow,  it 
is  first  dilated  by  means  of  the  above-mentioned  dilators.  The  tam- 
pons are  left  in  for  forty-eight  hours. 

In  order  to  get  the  cervix  and  lower  uterine  segment  dilated,  it  is 
sometimes  necessary  to  combine  the  use  of  these  cotton  balls  with  a 
bundle  of  laminaria  tents,  the  cotton  ball  being  pushed  up  in  the 
centre  of  the  bundle  as  far  as  the  middle  of  the  cervical  canal,  so  as 
to  form  a  cone  which  is  left  in  from  ten  to  fifteen  hours.  After  the 
dilatation  of  the  cervix  has  been  obtained  in  this  way,  only  cotton 
balls  are  used  and  the  packing  renewed.  Occasionally  this  method 
might  prove  valuable  both  for  diagnostic  purposes  and  for  the  re- 
moval of  tumors  from  the  cavity  of  the  body  of  the  womb. 

I.  Examination  of  Virgins. — The  vaginal  examination  ought  to  be 
avoided  as  much  as  possible  in  virgins.  In  cases  where  the  symptoms 
are  not  grave,  such  as  leucorrhea,  menstrual  disturbances,  backache, 
etc.,  it  is  better  to  desist  from  an  attempt  at  an  exact  diagnosis,  and  first 
try  the  effect  of  medical  treatment.  Some  information  may  be  gained 
by  the  rectal  exploration.  If,  however,  the  symptoms  point  toward 
more  serious  trouble,  a  vaginal  examination  becomes  imperative,  but 
1  Vulliet  et  Lntaud,  Lemons  de  Gynecologie  op&ratoire,  Paris,  1890,  p.  75. 


EXAMINATION  IN  GENERAL.  157 

ought  only  to  be  undertaken  with  great  care  and  deliberation.  Un- 
fortunately, many  girls  are  easy  enough  to  examine,  but  in  a  really 
intact  girl  the  introduction  of  the  finger  meets  with  considerable 
resistance,  and  the  sharp  edge  of  the  hymen  is  felt  like  a  fine  steel 
cord  on  the  pulp  of  the  finger.  With  the  exception  of  a  few  urgent 
cases,  in  which  it  is  necessary  for  treatment's  sake  to  make  a  speedy 
diagnosis,  it  is  better  first  to  prepare  the  hymen  by  the  introduction 
twice  daily  of  a  small  tampon  of  absorbent  cotton  soaked  in  glycerin. 
By  gradually  increasing  the  size  of  the  tampon  at  every  change  the 
parts  will  in  a  few  days  be  sufficiently  softened  and  dilated  to  allow 
the  index-finger  to  pass.  It  should  be  carefully  lubricated  all  over 
and  introduced  very  slowly,  in  order  to  avoid  causing  unnecessary  pain 
and  rupturing  the  hymen.  When  once  the  finger  has  passed,  a  small- 
sized  speculum  may  be  used  if  necessary. 

III.  The  Examination  of  the  Abdomen. — The  patient  occupies  the 
dorsal  position ;  the  physician  stands  at  her  right  side.  The  diag- 
nostic resources  at  his  command  are  inspection,  palpation,  percussion, 
auscultation,  mensuration,  injection  of  water  into  the  intestine,  and 
production  of  carbonic  acid  in  the  stomach. 

A.  Inspection. — The  practiced  eye  can  frequently,  at  the  first  glance, 
distinguish  the  more  pointed  prominence  caused  by  a  tumor  or  preg- 
nancy from  the  flat  enlargement  due  to  an  accumulation  of  free  fluid 
in  the  abdominal  cavity  or  to  hyperplasia  of  adipose  tissue.     We 
look  for  changes  in  pigmentation  (linea  fusca),  subepidermal  tears  in 
the  skin  (strice  albicantes),  and  the  protrusion  of  the  navel. 

B.  Palpation  is  superficial  or  deep.     By  folding  the  abdominal  wall 
we  judge  of  its  thickness  and  mobility.     By  slight  pressure  we  some- 
times get  a  crackling  sensation  due  to  fresh  adhesions.     By  deep 
pressure  we  try  to  gain  as  much  information  as  possible  about  the 
contents  of  the  abdomen.     We  examine  if  there  is  any  abnormal  ten- 
derness anywhere.     We  feel  for  hard  masses.     If  we  find  any,  we 
try  their  mobility.     If  it  is  the  uterus  that  is  enlarged  and  has  risen 
up  into  the  abdomen,  the  best  way  of  testing  its  mobility  is  to  place  the 
index-finger  on  the  os  and  move  the  fundus  from  side  to  side,  when  the 
cervix  will  be  felt  to  move  in  the  opposite  direction.     If  the  mass 
contracts  while  being  palpated,  we  know  that  is  the  gravid  uterus. 

If  a  patient  makes  a  deep  inspiration,  a  tumor  of  the  liver  will 
ascend  under  the  following  expiration  while  all  other  tumors  may 
be  kept  down  with  the  hands.1 

In  palpating  tumors  the  bimanual  examination  (Fig.  113,  p.  141) 
is  likewise  often  used.  The  physician  stands  then  between  the  legs 
of  the  patient.  Often  an  assistant  is  needed  to  lift  the  tumor  or 
move  it  from  side  to  side.  By  placing  the  fingers  of  one  hand  lightly 

1  Kaunyn,  reported  by  Minkowski,  Centralblatt  fur  Gynakologie,  1888,  vol.  xii. 
p.  790. 


158  DISEASES  OF  WOMEN. 

in  one  place  and  pressing  on  another  with  those  of  the  other  hand,  we 
ascertain  if  there  is  any  fluctuation — a  sign  which  denotes  the  presence 
of  a  fluid.  In  a  case  of  pregnancy  we  may  be  able  to  recognize  certain 
parts  of  the  fetus. 

C.  Pwcussion. — By  means  of  percussion  we  find  out  whether  we 
have  the  normal  tympanitic  sound  of  the  intestines  containing  gas,  or 
a  dull  or  flat  sound  characteristic  of  a  solid  mass  or  a  fluid.     We  note 
very  carefully  the  limits  of  the  dull  area,  by  which  we  get  valuable 
information  in  regard  to  the  starting-point  of  the  tumor.     If  it  is  a 
fluid,  we  make  the  patient  alternately  lie  on  the  back  and  on  either 
side  while  \ve  use  percussion.     If  the  fluid  sinks  down,  leaving  a 
tympanitic  area  above,  we  conclude  that  the  fluid  moves  freely  in  the  ab- 
domen (ascites),  whereas  it  cannot  change  position  if  enclosed  in  a  cyst. 

D.  Auscultation  often  gives  information  of  the  very  greatest  im- 
portance.    Whenever  we  have  to  examine  an  enlarged  abdomen  we 
ought  always  to  bear  pregnancy,  normal  or  extra-uterine,  in  mind  as 
the  key  to  the  whole  condition  or  as  a  complication.     We  listen, 
therefore,  for  the  double  sound  characteristic  of  the  fetal  heart,  for 
the  sound  caused   by  fetal  movements,  and  for  the  blowing  sound 
(uterine  souffle)  formed  in  the  large  vessels  running  along  the  sides 
of  the  womb.     The  latter  may,  however,  also  be  heard  in  fibro-cystic 
tumors  of  the  uterus.     The  bruit  produced  in  an  aneurism  of  the 
abdominal  aorta  has  a  different  character,  and  is  accompanied  by 
other  characteristic  signs. 

E.  Mensuration. — The  measures  are  taken  with  a  tape-measure  in 
the  dorsal  position.      This  method  is  especially  used  in  order  to  form 
an  idea  of  the  size  of  a  tumor,  and  gives  sometimes  information  in 
regard   to  its  starting-point.     The  measures  usually  taken  are  the 
girth  at  the  level  of  the  umbilicus,  the  girth  at  the  most  prominent 
point  of  the  swelling,  the  distance  from  the  umbilicus  to  the  symphy- 
sis,  the  ensiform  process,  and  the  anterior  superior  spine  of  the  ilium. 

F.  Development  of  gas  in  the  stomach  and  injection  of  water  into 
the  intestine  have  recently  been  recommended  for  diagnostic  purposes. 
The  stomach  is  expanded  by  giving  bicarbonate  of  sodium  and  tar- 
taric  acid  together.      Later  the  stomach  is  evacuated  by  introducing  a 
soft-rubber  oasophageal  sound,  and  tepid  water  is  injected  into   the 
intestine  by  means  of  a  fountain  syringe.     In  this  way  a  tumor  is 
displaced  in  the  direction  from  which  it  has  started.1 

G.  Charts. — It  saves  much  time  and  contributes  to  a  precise  diag- 
nosis to  use  printed  charts  representing  the  outline  of  the  abdomen 
and  pelvis  in  front  and  side  view,  and  mark  on  them  the  location  of 
any  swelling  found  by  examination.2 

1  Naunyn,  Centralblatt  f.  Gyn.,  1888,  vol.  xii.  p.  790. 

2  Rubber  stamps  for  recording  cases  are  manufactured  by  the  Barton  Manufactur- 
ing Co.,  No.  338  Broadway,  New  York. 


EXAMINATION  IN  GENERAL.  159 

IV.  Other  Means  of  Investigation  Common  for  Pelvic  and  Abdom- 
inal Diseases. — Such  are  exploratory  aspiration,  exploratory  incision, 
urinary  analysis,  microscopic  examination,  chemical  examination,  ex- 
amination under  anesthesia,  and  examination  of  the  ureters. 

A.  Exploratory  aspiration  is  used  less  now  than  it  was  some  years 
ago.     It  is  done  in  order  to  ascertain  the  presence  of  a  fluid  or  to 
obtain  a  sample  of  such  fluid  for  examination.      If  the  fluid  is  thin, 
it  may  be  drawn  out  by  the  common  hypodermic  syringe.     For  use 
in  the  vagina  such  a  syringe  has  been  made  with  a  longer  needle  and 
an  attachment  by  means  of  which  the  piston  can  be  pulled  out.1     In 
most  cases  it  is  preferable  to  use  a  real  aspirator,  such  as  Dieulafoy's, 
Potain's  (Fig.  138),  or  Emmet's.  •  Even  the  finest  hypodermic  nee- 
dle ought  to  be  carefully  disinfected  before  being  plunged  into  the 
interior  of  the  body,  and  the  same  precaution  ought  to  be  taken  in 
regard  to  the  skin  it  is  going  to  perforate.     As  a  rule,  a  cavity  once 
entered  should  be  totally  emptied  in  order  to  prevent  the  fluid  from 
finding  its  way  into  the  peritoneal  cavity.     As  this  may  be  very 
tedious,  a  syphon  action  may  be  substituted  for  the  aspiration   by 
attaching  a  rubber  tube  to  the  needle  and  placing  the  other  end, 
armed  with  a  plunger,  in  a  vessel  with  water.     Aspiration  ought 
never  to  be  performed  in  the  office  or  dispensary,  and  the  patient 
ought  to  be  kept  in  bed  for  four  days.    In  order  to  lessen  as  much  as 
possible  the  danger  of  wounding  blood-vessels,  the  finest  instrument 
that  will  do  the  work  is  preferable,  and  it  ought  to  be  introduced 
slowly,  so  as  to  push  arteries  aside  which  it  might  meet  in  its  way.    If 
the  puncture  is  made  through  the  skin,  the  opening  should  be  pressed 
together  from  side  to  side  and  covered  with  a  piece  of  rubber  adhesive 
plaster.     (Compare  "  Tapping,"  under  Treatment  of  Ovarian  Cysts.) 

B.  Exploratory  Incision. — With  the  increasing  iunocuousness  of 
opening  the  peritoneal  cavity  the  exploratory  incision  has  to  a  great 
extent  replaced  exploratory  aspiration.    It  is,  of  course,  in  many  cases 
only  the  first  act  of  a  capital  operation,  and  must  therefore  only  be 
undertaken  by  a  person  qualified  to  perform  the  latter,  and  after  all 
preparations  for  such  an  operation  have  been  made.    The  incision  may 
be  made  through  the  abdominal  wall  or  through  the  vagina.     The 
incision  in  the  abdominal  wall  is  not  made  larger  than  is  necessary  to 
clear  up  the  existing  doubt,  for  which  purpose  the  introduction  of  one 
or  two  fingers  often  suffices.    As  a  rule,  it  is  made  in  the  median  line 
and  so  that  the  lower  end  of  the  incision  comes  to  lie  two  finger- 
breadths  above  the  symphysis  pubis. 

The  exploratory  incision  in  the  vagina  may  be  made  in  the  anterior 
or  the  posterior  vault.  In  most  cases  an  opening  in  the  posterior 
vault  large  enough  to  admit  two  fingers  allows  us  to  explore  the  whole 

1  Campbell,  southwest  corner  Lexington  Avenue  and  Thirty-fourth  Street,  has 
made  such  a  syringe  for  me. 


160 


DISEASES  OF  WOMEN. 


pelvis,  and,  this  being  the  simpler  operation,  it  should,  as  a  rule,  be 
preferred.1  The  incision  may  be  made  either  transversely  at  the  utero- 
vaginal  junction,  or  perpendicularly,  extending  from  the  cervix  to  the 
bottom  of  Douglas's  pouch.  In  exceptional  cases  the  anterior  incision 
is  preferable,  which  involves  the  separation  of  the  bladder  from  the 
uterus  (see  Vaginal  Hysterectomy). 


Aspirator.  This  instrument  consists  of  a  clear  glass  bottle,  with  a  graduated  scale  showing 
the  amount  of  fluid  contained.  It  is  closed  by  a  rubber  stopper,  through  the  centre  of 
which  a  double-current  tube,  2,  passes.  It  is  attached  to  an  elastic  hose,  3,  with  an  ex- 
hausting pump,  4,  and  another  elastic  hose,  5,  with  a  stopcock,  6.  On  the  top  of  the  latter 
fit  needles  and  trocars,  7,  of  different  sizes. 

C.  Urinary  analysis  ought  to  be  made  in  every  case  before  an  ope- 
ration is  undertaken,  and  even  before  the  patient  is  subjected  to  the 
influence  of  anesthetics,  as  the  result  of  the  analysis  may  decide  which 
anesthetic  should  be  preferred  (see  Anesthesia).  But  even  in  minor 

1  Garrigues,  "  Vaginal  Hysterectomy  and  Oophorectomy  after  Symphysiotomy," 
Med.  Record,  Feb.  23,  1895,  vol.  xlvii.  No.  8,  p.  234. 


EXAMINATION  IN  GENERAL.  161 

gynecology  the  examination  of  the  urine  often  gives  valuable  hints  as 
to  diagnosis  or  treatment.  The  urine  should  be  examined  chemically 
and  microscopically. 

D.  Catheterization  of  Bladder. — In  most  cases  the  patient  may  pass 
her  urine  herself  and   send  it  for  examination,  but  if  there  is  any 
complaint  referable  to  the  bladder,  the  urine  should  be  drawn  with 
the  catheter.     To  do  this  under  the  clothes  is  easy  enough,  but  entirely 
antiquated.     We  know  that  by  introducing  mucus  from  the  vagina 
or  vulva  into  the  bladder  we  may  set  up  cystitis.     The  meatus  urin- 
arius  should,  therefore,  be   exposed,  the  patient  being  either  in  the 
dorsal  or" left-lateral  position.     The  vulva  is  opened  with  the  fingers 
of  the  left  hand,  and  the  vestibule  wiped  with  a  pledget  of  absorbent 
cotton  wrung  out  of  an   antiseptic   solution.     Next  the  disinfected 
catheter,  held  with  the  thumb  and  index-finger  of  the  right  hand,  is 
introduced.     A  metallic  catheter  is  preferable,  as  it  is  easier  to  keep 
clean,  and  in  many  examinations  a  stiff  rod  is  needed.     It  ought  to 
be  smeared  with  vaseline  or  olive  oil,  and  introduced  in  a  curve 
hugging  the  symphysis  pubis. 

E.  Microscopical  examination  is  of  great  diagnostic  value  for  the 
gynecologist.     It  is  applied  to  the  urine,  pathological  fluids  obtained 
by  aspiration,  and  solid  bodies  removed  with  the  curette  or  cutting 
instruments.     In    examining    urine   special   attention  is  paid  to  the 
presence  of  epithelial  cells  from  the  different  parts  of  the' urinary 
tract  and  the  external  genitals  (Fig.  139),  to  casts  characteristic  of 
nephritis,  and  to  the  different  crystals  abnormally  seen  in  urine.1 

As  a  sample  of  fluid  let  us  take  that  from  an  ecchinococcus.  A 
single  booklet  or  a  particle  of  the  structureless  stratified  cuticula, 
revealed  by  the  microscope,  settles  the  diagnosis.  A  piece  of  tissue 
scraped  off  with  a  curette  or  cut  off  with  scissors  may  tell  us  if  it 
comes  from  a  part  affected  with  carcinoma. 

F.  Chemical  Examination.  —  Chemical  reactions  are  especially  used 
to  reveal  the  presence  of  sugar,  albumin,  or  gall  in  urine  or  other 
fluids. 

G.  Examination  under  anesthesia  is,  of  course,  only  used  in  more  im- 
portant cases,  since  the  process  always  contains  an  element  of  danger ; 
but  this  is  so  small,  and  the  benefit  to  be  derived  for  the  diagnosis  so 
great,  that  this  means  of  investigation  is  perfectly  justifiable.     Some 
women  contract  their  muscles  so  persistently  that  it  is  impossible  to 
make  a  thorough  examination  without  having  recourse  to  this  means, 
when  often  the  existence  of  a  condition  calling  for  active  interference 
will  be  brought  to  light. 

H.  Examination  of  the  Bladder  and  the  Ureters. — The  size,  sensi- 

1  For  details  the  reader  is  referred  to  the  work  of  Charles  Heitzmann,  Microscopic 
Morphology  of  the  Animal  Body  in  Health  and  Disease,  New  York,  1883,  with  its 
excellent  illustrations. 
11 


162 


DISEASES  OF  WOMEN. 


tiveness,  and  elasticity  of  the  bladder  can  be  tested  with  a  metal  cath- 
eter, and  its  inside  can  be  seen  with  the  galvanic  cystoscope  or  the 
bladder-speculum. 


FIG.  139. 


Epithelial  Cells  found  in  Urine  X  500  (C.  Heitzmann) :  B,  from  bladder,  superficial  layer ; 
BM,  from  middle  layers  of  bladder ;  BD,  from  deepest  layer  of  bladder ;  P,  from  the 
prostate ;  E,  from  the  ejaculatory  duct ;  V,  from  superficial  layer  of  vagina ;  \'M,  from 
middle  layers  of  vagina ;  VD,  from  deepest  layer  of  vagina ;  C,  from  the  outer  surface  of 
the  cervix  uteri ;  U,  from  the  cavity  of  the  ute'rus ;  PK,  from  pelvis  of  kidney ;  KC,  from 
the  convoluted  tubes  of  the  kidney  ;  KS,  from  the  straight  tubes  of  the  kidney. 

The  galvanic  cystoscope  is  an  instrument  that  has  somewhat  the 
shape  of  a  lithotrite  and  carries  a  minute  Edison  electric  lamp  into  the 
bladder,  the  whole  inside  of  which  can  be  made  distinctly  visible. 


EXAMINATION  IN  GENERAL. 


163 


The  instrument  can  be  introduced  without  dilatation  through  any 
urethra  admitting  a  No.  23  French  bougie.1 

Howard  Kelly's  bladder-speculum2  necessitates  previous  dilatation 
of  the  urethra,  but  offers  the  advantage  that  the  inside  of  the  bladder 
can  not  only  be  seen,  but  can  be  treated  locally  on  any  limited  area. 
The  patient  is  at  first  placed  in  the  common  dorsal  position,  and  the 
bladder  emptied  with  a  catheter.  By  means  of  a  coniform  calibrator 

FIG.  140. 


Kelly's  Urethral  Dilators. 


introduced  into  the  urethra  as  far  as  it  will  readily  go,  the  measure 
of  the  meatus  urinarius  is  taken.  A  dilator  (Fig.  140)  of  the  same 
size  is  inserted  instead  of  the  calibrator,  and  gradually  replaced  by 
thicker  ones.  The  average  female  urethra  can  easily  be  dilated  up  to 
12  millimeters  in  diameter  with  only  a  slight  external  rupture.  As 

FIG.  141. 


Method  of  Holding  the  Speculum  during  Introduction,  the  thumb  pressing  upon  the 
handle  of  the  obturator  (Kelly). 

soon  as  a  dilatation  of  12  to  15  millimeters  is  reached,  a  speculum 
(Fig.  141)  of  the  same  diameter  as  the  last  dilator  is  introduced  and 

1  Willy  Meyer,  "  On  Cystoscopy  and  the  New  Cvstoscope  of  Nitze  and  Leiter," 
N.  Y.  Med.  Journ.,  April  21,  1888. 

2  This  method  and  the  instruments  used  have  been  claimed  by  Pawlik  as  his 
(Amer.  Jour.  Obst.,  March,  1896,  vol.  xxxiii.  pp.  387-405,  and  August,  1896,  vol. 
xxxiv.  pp.  253-261). 


164 


DISEASES  OF  WOMEN. 


its  obturator  removed.  The  hips  of  the  patient  are  now  elevated  on 
cushions  8  to  16  inches  above  the  table.  The  examiner  puts  on  a 
head-mirror  in  a  dark  room,  and  reflects  the  light  from  a  source  held 
close  to  the  patient's  symphysis  pubis;  or  a  good  direct  light  from  a 
window  will  suffice.  Upon  withdrawing  the  obturator,  the  pelvis 
being  elevated,  the  bladder  becomes  distended  with  air.  If  a  pool  of 
urine  remains  in  the  bladder,  it  should  be  withdrawn  by  a  suction 
apparatus  made  for  the  purpose  (Fig.  142).  If  the  residuum  is  not 

FIG.  142. 


Suction  Apparatus  (three-fourths  natural  size),  used  for  withdrawing  residual  urine  (Kelly). 

more  than  2  or  3  cubic  centimeters,  it  can  easily  be  removed  by  little 
balls  of  absorbent  cotton  grasped  with  a  long  mouse-toothed  forceps. 
In  some  inflammatory  cases  the  bladder  will  not  balloon  out  in  the 
ordinary  position,  owing  to  its  thickened  walls.  Then  the  genu-pec- 
toral  position  (p.  138)  is  used.  This  position  is,  upon  the  whole,  best 
for  a  first  examination.  If  the  patient  cannot  remain  long  enough  in 
this  position,  its  advantages  may  often  be  secured  by  placing  her  for 
a  short  time  in  that  position  until  the  viscera  gravitate  up  and  out  of 
the  pelvis,  and  introducing  a  catheter  into  the  bladder,  which  at  once 
fills  with  air.  The  catheter  is  now  withdrawn,  and  the  patient  gently 
returned  to  the  dorsal  position  with  more  or  less  elevated  hips.  Upon 
introducing  the  speculum  the  bladder  will  be  found  distended  with  air. 
In  nervous  patients  it  is  often  best  first  to  make  a  thorough  examina- 
tion under  anesthesia.  A  pledget  of  absorbent  cotton  saturated  with 
a  5  per  cent,  solution  of  cocaine  and  left  for  five  minutes  in  the  urethra 
greatly  facilitates  the  dilatation  and  is  often  the  best  form  of  anesthesia.1 
The  ureters  may  be  examined  by  inspection,  by  catheterization,  and 
by  palpation. 

1  Howard  Kelly,  Amer.  Jour.  Obst.,  January  and  July,  1894. 


EXAMINATION  IN   GENERAL.  165 

With  the  galvanic  cystoscope  the  nreteral  openings  can  be  seen,  as 
well  as  the  discharge  of  urine  that  takes  place  through  them.  In 
cases  of  unilateral  pyelonephritis  clear  urine  is  seen  coming  through 
one  of  the  openings,  and  a  purulent  fluid  through  the  other.  Casper's 
improved  galvanic  cystoscope  allows  one  also  to  introduce  a  fine  flexi- 
ble catheter  into  the  ureter. 

If  Kelly's  bladder-speculum  is  used,  by  elevating  the  handle  of  the 
instrument  the  field  of  vision  sweeps  over  the  base  of  the  bladder 
until  the  region  of  the  interureteric  ligament  comes  into  view,  often 
marked  by  a  transverse  fold  or  a  distinct  difference  in  color.  By 
turning  the  speculum  thirty  degrees  to  one  side  or  the  other  and  look- 
ing sharply,  a  ureteral  orifice  is  discovered.  In  order  to  ascertain  that 
it  is  the  ureter  which  lies  in  the  field,  a  searcher — that  is  a  long  deli- 
cate sound  with  a  handle — is  introduced  through  the  speculum  into 
the  supposed  ureteral  opening.  If  it  is  the  ureter,  the  searcher  passes 
easily  from  2  to  6  centimeters  up  the  canal.  The  searcher  may  then 
be  replaced  by  a  metal  catheter  or  by  hard-rubber  bougies,  which  lat- 
ter may  be  introduced  before  hysterectomies  and  prevent  injury  to  the 
ureters  during  the  operation.  After  some  practice  it  is  possible  even 
to  catheterize  the  ureters  with  the  patient  in  the  dorsal  position  with- 
out elevating  the  pelvis.  Commonly  a  speculum  10  millimeters  in 
diameter  suffices  for  inspection,  catheterization,  and  treatment  of  the 
ureters. 

Catheterization  of  the  Ureters  by  PawliK's  Method. — The  anterior 
vaginal  wall  presents  folds  corresponding  to  the  trigone  (Figs.  83  and 
143),  and  permitting  us  to  locate  the  openings  of  the  ureters.  The 
patient  is  placed  in  the  dorsal  position,  with  legs  strongly  flexed  on 
the  abdomen,  and  the  posterior  vaginal  wall  drawn  down  with  a  single 
Sims  speculum.  A  delicate  catheter  (Fig.  144)  is  then  carried  into  the 
bladder,  and  poised  between  thumb  and  index-finger.  The  position  of 
the  end  of  the  catheter  is  plainly  seen  in  the  vagina  as  it  sweeps  gently 
over  the  floor  of  the  bladder.  The  ureteral  orifice  is  to  be  sought 
for  about  an  inch  back  of  the  internal  opening  of  the  urethra  and 
about  one-half  or  three-quarters  of  an  inch  from  the  median  line  on 
either  side.  This  position  of  the  ureter,  however,  is  not  constant, 
and  cannot  be  relied  upon  alone.  Far  more  characteristic  is  the 
slight  tripping  sensation  given  to  the  point  of  the  catheter  as  it 
glides  over  the  ureteral  prominence.  As  soon  as  this  sensation  is  per- 
ceived the  catheter  must  be  at  once  brought  back  to  the  place  where 
it  was  felt,  and  gentle  attempts  made  to  engage  its  point  by  repeatedly 
carrying  the  handle  upward  and  outward  to  the  other  side,  and  direct- 
ing the  point  toward  the  posterior  lateral  wall  of  the  pelvis.  With 
each  of  these  sweeping  motions  the  catheter  is  rotated  until  the  point 
is  directed  fully  outward  or  slightly  upward.  Once  caught,  the 
catheter  sweeps  readily  in,  and,  if  lightly  held,  directs  its  own  course, 


166 


DISEASES  OF  WOMEN. 


the  fingers  simply  following.  The  anterior  vaginal  wall  is  seen  lifted 
up  in  advance  and  to  one  side  of  the  cervix,  forming  a  distinct  pocket 
on  the  side  on  which  the  ureter  is  being  catheterized. 

FIG.  143. 


Pawlik's  Vaginal  Trigone,  corresponding  to  Lieutaud's  vesical  trigone  :  L,  labia  minqra  ;  0, 
ir.eatus  urinarius ;  O,'  O,'  urethral  ledge  ;  .S,  »S,  lateral  folds  corresponding  to  the  sides  of 
the  vesical  trigone  ;  B,  fold  corresponding  to  the  basis  of  the  vesical  trigone ;  V,  vaginal 
portion  of  uterus. 

Before  trying  to  catheterize  the  ureters  the  bladder  is  injected  with 
about  six  ounces  of  a  blue  anilin  solution,  which  removes  rugosities  of 

FIG.  144. 


Pawlik's  Ureteral  Catheter. 


the  bladder,  makes  Pawlik's  folds  more  distinct,  and  by  the,  difference 
of  the  color  of  the  fluid  shows  when  the  ureter  has  been  reached.1 
1  Howard  Kelly,  Annals  of  Gynecology  and  Pcediatry,  August,  1893,  p.  642. 


EXAMINATION  IN  GENERAL.  167 

On  withdrawing  the  stopper  of  the  catheter  a  few  drops  of  urine 
run  out,  and  then  cease,  keeping  up  an  intermittent  discharge  entirely 
characteristic.  The  catheter  can  be  pushed  beyond  the  brim  of  the 
pelvis,  up  to  the  pelvis  of  the  kidney,  by  introducing  an  index-finger 
into  the  rectum,  and  lifting  and  guiding  the  catheter  while  it  is  being 
pushed  up.  Sometimes  the  ureters  may  even  be  catheterized  without 
anesthetizing  the  patient. 

Palpation  of  the  Ureters. — When  there  is  no  disease  the  ureters 
can  usually  be  felt  with  facility  as  more  or  less  flat  cords  about  one- 
eighth  of  an  inch  in  diameter,  movable  to  an  extent  of  one-half  to 
three-quarters  of  an  inch,  in  the  loose  pelvic  connective  tissue  at  the 
side  and  in  front  of  the  cervix.  The  patient  may  be  in  the  dorsal 
position,  and  both  hands  used,  the  homonymous  index-finger  in  the 
vagina  (i.  e.  the  left  for  the  left  ureter,  the  right  for  the  right),  or 
she  may  be  in  Sims's  position.  In  both  positions  the  vaginal  roof 
is  pushed  well  upward,  when  the  ureter  may  be  felt,  hooked,  brought 
down,  and  compressed. 

A  practical  and  safe  method  of  obtaining  urine  from  one  ureter 
alone  is  very  desirable  in  order  to  locate  and  treat  disease  there,  and 
to  ascertain  the  presence  and  healthy  condition  of  the  second  kidney, 
when  the  removal  of  one  is  contemplated. 

It  goes  without  saying  that  the  puke  should  be  counted  and  its 
character  noted,  the  temperature  measured  with  a  clinical  thermometer, 
and  such  other  investigations  made  in  regard  to  the  condition  of  other 
organs  and  the  general  health  of  the  patient  as  the  case  may  call  for. 


PART  VI. 

TREATMENT  IN  GENERAL. 

THE  treatment  of  gynecological  diseases  is  preventive  and  curative  ; 
the  latter,  again,  is  carried  out  by  external  manipulations,  by  the  inter- 
nal  use  of  drugs,  or  by  electricity. 


CHAPTER  I. 
PREVENTIVE  TREATMENT. 

WHAT  can  be  done  and  is  to  be  attempted  in  the  way  of  pre- 
venting gynecological  diseases,  can  easily  be  inferred  from  a  study 
of  the  chapter  on  etiology,  but  the  beginner  must  not  be  too 
sanguine  in  his  expectations  or  too  positive  in  his  demands,  if  he 
will  avoid  disappointment  or  the  loss  of  his  patient.  As  soon  as 
his  advice  clashes  with  that  of  the  dressmaker  or  social  habits,  ninety- 
nine  women  will  be  decided  by  these  last  two  factors  for  one  who 
will  follow  the  first.  Where  this  antagonism  does  not  come  into  play, 
much  good  may,  however,  be  done  by  timely  warning. 

At  puberty  girls  should  not  be  exposed  to  mental  overwork,  and 
at  no  time  should  the  practice  of  music  be  carried  so  far  as  to  engen- 
der nervousness.  All  sexual  excesses  and  unnatural  practices  should 
be  avoided.  The  skin  should  be  kept  clean.  The  muscles  should  be 
strengthened  by  exercise  and  games.  Some  time,  at  least  an  hour 
every  day,  should  be  spent  in  the  open  air.  Good,  wholesome  food 
should  be  taken  at  proper  times,  and  in  sufficient  quantity  to  make 
up  for  the  physiological  tissue-consumption.  The  bladder  should  be 
emptied  when  a  desire  is  felt  to  do  so.  An  evacuation  from  the 
bowels  should  take  place  once  or  twice  a  day.  The  body  should  be 
sufficiently  covered,  especially  in  the  cold  season.  In  winter  time 
women  should  wear  woollen  drawers,  but  they  should  not  be  "  closed," 
as  this  tempts  to  neglect  proper  evacuation  of  the  bladder.  Corsets 
ought  to  be  banished  from  the  dress  of  children,  girls,  and  young 
women.  All  of  them  ought  to  go  early  to  bed — as  a  rule,  not  later 

168 


TREATMENT  IN  GENERAL.  169 

than  ten  o'clock.  During  menstruation  they  should  carefully  avoid 
exposure,  violent  exercise,  or  sexual  intercourse.  If  suffering  from 
chronic  pelvic  inflammation  they  had  better  abstain  from  marriage. 
Good  midwifery,  both  as  to  surgical  help  and  conscientious  use  of 
antiseptics,  not  only  in  hospitals,  but  in  private  practice,1  goes  far  to 
prevent  later  disease.  Puerperse  should  be  kept  in  bed  until  the 
uterus  has  receded  into  the  pelvis. 

Lacerations  of  the  cervix  and  the  perineum,  if  not  healed  immedi- 
ately after  delivery,  should  be  repaired  by  the  proper  operations 
before  the  bad  effects  consequent  upon  them  make  their  appearance. 
Women  should  be  told  to  what  enormous  dangers  they  expose  them- 
selves by  availing  themselves  of  abortionists,  and  miscarriages  should 
be  treated  with  great  care  according  to  the  tenets  of  modern  mid- 
wifery, and  especially  all  the  products  of  conception  should  be  re- 
moved. Antiseptic  precautions  should  be  taken  as  far  as  feasible, 
even  in  minor  gynecological  operations  and  examinations.  A  man 
who  has  had  a  gonorrhea  should  not  marry  before  a  careful  examina- 
tion by  a  competent  judge  has  ascertained  that  he  is  perfectly  cured. 

1  The  writer  has  since  1883  repeatedly  called  the  attention  of  the  profession 
to  the  importance  of  aseptic  and  antiseptic  midwifery.  He  was  the  first  to  in- 
troduce strict  antisepsis  in  this  country.  On  the  first  day  of  October,  1883,  the 
whole  arrangement  of  the  New  York  Maternity  Hospital  was  changed,  and  the 
results  were  so  striking  that  the  example  was  soon  followed  by  others,  and  that  the 
treatment  then  inaugurated  has  been  kept  up  ever  since  with  insignificant  modifica- 
tions. His  first  report  was  given  in  a  paper  on  "  The  Prevention  of  Puerperal 
Infection  "  read  before  the  Medical  Society  of  the  County  of  New  York,  and  pub- 
lished in  the  Medical  Record,  December  29,  1883,  vol.  xxiv.,  pp.  703-706.  Soon 
followed  an  article  under  the  same  title,  especially  on  the  use  of  injections,  published 
in  the  New  York  Medical  Journal,  March  1, 1884.  Then  came  a  paper  on  "  Puerperal 
Diphtheria"  published  in  Transactions,  Amer.  Gynecol.  Soc.,  vol.  x.  1885,  pp.  96-113. 
Next,  he  treated  the  whole  subject  of  puerperal  infection  at  greater  length  in  book- 
form  in  his  Practical  Guide  in  Antiseptic  Midwifery,  Detroit,  Mich.,  1886,  and  in  a  long 
article  on  "Puerperal  Infection"  in  the  American  System  of  Obstetrics,  edited  by 
Hirst,  Philadelphia,  1889,  vol.  ii.  pp.  290-378,  as  well  as  in  a  similar  article  in  the 
American  Text-book  of  Obstetrics,  edited  by  Norris,  Philadelphia,  1895,  pp.  683-734. 
The  article  on  "Corrosive  Sublimate  and  Creolin"  in  Amer.  Jour.  Med.  Sci.,  Au- 
gust, 1889,  contained  the  only  change  he  in  the  course  of  time  found  it  advisable 
to  make. 

In  hospital  practice  strict  antisepsis  is  now  used  everywhere,  but  in  private  prac- 
tice we  lag  yet  in  a  deplorable  way  behind  other  countries,  and  the  result  is  to  be 
found  in  frequent  disease  and  death  among  the  well-to-do,  which  have  nearly  dis- 
appeared from  the  lying-in  hospitals.  It  is  to  be  hoped  that  the  general  practitioner 
soon  will  follow  the  lead  of  the  expert  obstetrician  in  this  field.  At  my  motion  the 
following  resolution  was  unanimously  adopted  on  October  27, 1892 ;  "  In  the  opinion 
of  the  Section  on  Obstetrics  and  Gynecology  of  the  New  York  Academy  of  Medi- 
cine, it  is  the  duty  of  every  physician  practicing  midwifery  to  surround  such  cases 
in  private  practice  with  the  same  safeguards  that  are  being  used  in  hospitals  "  (Garri- 
gues,  "Reprehensible,  Debatable,  and  Necessary  Antiseptic  Midwifery,  Med.  JVeics, 
Nov.  26,  1892). 


170  DISEASES  OF  WOMEN. 

CHAPTER  II. 

EXTERNAL  TREATMENT. 

A.  Applications. — Applications  of  medicinal  substances  are  made 
to  the  vagina  or  to  the  uterus.  The  patient  is  in  Sims's  position,  the 
parts  are  exposed  with  Sims's  speculum  and  my  depressor  (p.  149). 
After  having  wiped  the  mucus  off  with  absorbent  cotton,  the  vaginal 
vault  is  painted  with  common  tincture  of  iodine,  by  means  of  a  large 
camel's-hair  brush  on  a  long  handle.  The  throat-brushes  with  wooden 
handle  that  are  found  in  the  drug-stores,  are  quite  serviceable  for  this 
purpose.  As  the  iodine  smarts  when  it  reaches  the  vulva,  care  should 
be  taken  not  to  fill  the  brush  too  much,  and  to  wipe  the  superfluous 
fluid  off  with  absorbent  cotton  before  the  patient  rises.  In  the  vagina 
I  prefer  the  common  tincture  of  iodine  to  Churchill's,  as  I  have  seen 
the  latter  produce  ulceration. 

For  applications  to  the  interior  of  the  uterus  an  applicator  is  needed. 
Budd's  (Fig.  145),  which  is  a  flexible  flattened  hard  rubber  stick,  is 
as  good  as  any,  recommends  itself  by  its  simplicity,  and  is  easy  to  keep 

FIG.  145. 


Budd's  Uterine  Applicator. 

clean.  It  is  sold  straight,  but  it  ought  to  be  curved  like  a  sound. 
This  is  easily  done  by  warming  it  over  an  alcohol  lamp  and  bending  it. 

A  little  absorbent  cotton  is  fashioned  so  as  to  form  a  thin  rectan- 
gular pledget,  3  inches  long  by  1  wide.  The  applicator  is  held  at  right 
angles  a  little  inside  of  one  of  the  ends  and  one  of  the  sides,  and  the 
cotton  is  rolled  round  it  with  the  fingers  of  the  left  hand,  going  down 
in  a  spiral  line  toward  the  handle.  By  a  little  practice  it  becomes 
easy  to  put  it  on  smoothly  and  of  variable  thickness,  according  to  the 
caliber  of  the  cervical  canal.  The  thick  mucus  that  is  often  found 
in  the  cervical  canal  must  first  be  \viped  off  with  dry  cotton,  or,  if 
this  proves  impossible,  it  is  coagulated  by  applying  a  mixture  of 
equal  parts  of  tincture  of  iodine,  tannin,  and  carbolic  acid. 

Some  prefer  to  make  applications  to  the  inside  of  the  uterus  by 
means  of  a  glass  pipette,  or  through  a  cervical  speculum  (p.  150). 
If  the  canal  is  too  narrow  it  must  be  dilated  (p.  154).  For  the  endo- 
metrium,  I  use  mostly  Churchill's  tincture  of  iodine,  liquor  ferri 
chloridi  undiluted,  chloride  of  zinc  (20  to  50  per  cent.),  and  occa- 
sionally sol.  argent,  nitrat.  1  to  12,  or  pure  carbolic  acid. 

As  some  patients  are  very  sensitive  to  intra-uterine  applications,  it 


TREATMENT  IN  GENERAL. 


171 


is  best  to  restrict  the  first  application  to  the  cervix,  and  gradually 
penetrate  into  the  cavity  of  the  body  up  to  the  funclus. 

Drugs  may  also  be  made  up  as  ointments,  and  applied  in  the  inte- 
rior of  the  womb  by  means  of  Barnes's  ointment  carrier,  a  silver  tube 
with  large  side  openings  and  a  piston.  Or  they  may  be  incorporated 
in  small  rods,  so-called  bacilli,  made  with  cacao-butter  or  althaea, 
which  are  pushed  through  a  metallic  tube  with  open  end  (E.  Martin's 
pistol).  Powders,  especially  boracic  acid,  iodoform,  and  aristol,  may 
be  applied  in  the  interior  of  the  uterus  by  means  of  a  similar  instru- 
ment. All  these  tubuliform  instruments  have,  however,  the  grave 
drawback  that  it  is  next  to  impossible  to  keep  them  clean.  I  have, 
therefore,  of  late  years,  discarded  them  all  in  favor  of  the  applicator 
wound  with  cotton. 

Applications  are,  as  a  rule,  repeated  twice  a  week. 

B.  Injections. — Injections  are  made  into  the  vagina,  the  uterus, 
the  rectum,  and  the  bladder,  with  plain  or  medicated  water,  by  means 
of  a  syringe. 

Vaginal  injections  are  used  to  greatest  advantage  in  the  dorsal  posi- 
tion on  a  bed-pan  (Fig.  146).  A  good  bed-pan  should  be  large,  and 
have  an  opening  near  the  bottom  with  an  attached  rubber  tube  to 
carry  off  the  water  into  a  larger  vessel  placed  under  the  bed.  If  it  does 
not  have  such  a  contrivance,  and  is  not  large  enough,  the  water  may 

FIG.  146. 


Bed-pan,  holds  nearly  seven  pints :  A,  tube  closed  with  plug,  B,  unless  used  to  make  connec- 
tion with  rubber  hose  leading  to  vessels  placed  under  the  bed  ;  C,  tube  for  emptying  pan ; 
£>,  cover  to  be  screwed  on  the  same  when  not  in  use. 

be  gradually  pumped  out  by  means  of  a  bulb-and-valve  syringe 
(Davidson's  syringe)  while  running  into  the  bed-pan. 

Patients  who  are  obliged  to  help  themselves  may  also  take  their 
vaginal  douche  standing  over  a  chamber-pot  placed  on  a  chair,  or 
sitting  on  a  bidet. 

It  is  best  to  use  a  fountain  syringe;  that  is,  a  bag  of  soft  rubber, 
or  a  metal  pail,  a  so-called  douche-can,  with  a  long  soft  rubber  tube 
and  a  nozzle  of  metal  or  preferably  hard  rubber.  The  nozzle  should 
only  have  holes  at  or  near  the  end,  and  it  should  be  pushed  in  so  far 
that  the  openings  are  behind  and  above  the  os  uteri.  If  there  are 


172  DISEASES  OF  WOMEN. 

side  openings  lower  down  or  the  nozzle  is  not  introduced  to  the  proper 
depth,  an  opening  may  face  the  os  and  some  fluid  be  injected  into  the 
uterus,  which  gives  rise  to  a  very  painful  and  alarming  uterine  colic. 

If  the  chief  aim  of  the  injection  is  to  combat  inflammation  and 
cause  absorption  of  inflammatory  exudations,  plain  hot  water  is  the 
best.  The  amount  should  not  be  less  than  two  quarts.  The  tem- 
perature should  be  as  high  as  the  patient  can  stand  it — i.  e.  so  that 
she  just  can  hold  her  hand  in  it  (110°  to  115°  F.).  In  exceptional 
cases  hot  water  increases  instead  of  relieving  pain,  and  is  then  advan- 
tageously replaced  by  lukewarm  water.  Cold  injections  are  injurious. 

For  merely  cleansing  the  vagina — for  instance,  when  a  pessary  is 
worn — a  pint  of  tepid  water  suffices,  and  its  effect  may  be  increased 
by  adding  a  heaping  teaspoonful  of  common  salt  or  bicarbonate  of 
sodium. 

If  an  astringent  is  called  for,  alum,  borax,  or  equal  parts  of  sul- 
phate of  copper  and  alum  are  dissolved  in  the  water.  Of  alum  or 
borax,  a  teaspoonful  is  added ;  of  the  mixture  of  copper  and  alum, 
only  half  a  teaspoonful. 

If  there  is  a  spongy  os  uteri  giving  rise  to  hemorrhage,  I  use  half 
a  teaspoonful  of  the  liquor  ferri  chloridi  to  a  pint  of  water. 

For  antiseptic  injections  carbolic  acid  (1  to  2  per  cent.)  or  creolin 
(^  to  1  per  cent.)  are  used.  The  latter  is  also  an  excellent  hemo- 
static,  but  in  some  patients  it  produces  a  smarting  sensation.  Bichlo- 
ride of  mercury  should  be  avoided,  except  for  gonorrhea,  on  account 
of  its  poisonous  properties,1  and  the  solution  should  not  be  stronger 
than  1  to  3000  or  even  5000. 

As  an  emollient  injection  a  decoction  of  flaxseed  tea  or  slippery-elm 
bark,  a  heaping  teaspoonful  to  each  quart  of  water,  is  good. 

Vaginal  douches  are,  in  chronic  cases,  as  a  rule,  used  morning  and 
evening,  and  in  acute  three  times  a  day,  or  even  every  three  hours. 

Intra-uterine  injections  are  much  more  dangerous  than  vaginal 
injections,  and  should  always  be  administered  by  the  physician  him- 
self. We  distinguish  between  small  and  large  intra-uterine  injections. 
The  former  are  really  only  applications  of  drugs  made  on  a  larger 
scale.  The  injection  is  made  by  means  of  a  small  glass  syringe  with 
a  long  nozzle,  with  one  or  more  fine  openings  near  the  end  (Fig. 
147).  Having  seen  several  cases  of  alarming  collapse  follow  the  use 
of  this  method,  and  knowing  that  it  has  been  fatal  in  the  hands  of 
others,  I  have  entirely  discarded  it. 

Large  uterine  injections  are  used  for  cleaning  and  disinfecting  the 
uterus  and  for  checking  hemorrhage.  If  the  cervix  has  been  thor- 
oughly dilated  before  injecting,  a  single-current  tube  is  preferable,  as 
it  leaves  more  room  for  evacuation  of  large  ddbris.  For  this  purpose 

1  Garrigues,  "Corrosive  Sublimate  and  Creolin  in  Obstetric  Practice,"  Amer.  Jour. 
Med.  Sci.,  Aug.,  1889,  vol.  xcviii.  pp.  109-128. 


TREATMENT  IN  GENERAL.  173 

I  find  the  so-called  soft-metal  male  catheters  sold  in  the  stores  of  the 
instrument-makers  very  convenient,  as  they  are  easily  bent  so  as  to 
adapt  themselves  to  any  shape  of  the  uterine  canal.  By  adding  a 
flange  at  the  open  end,  connection  is  easily  established  with  a  fountain 

FIG.  147. 


Braun's  Uterine  Syringe. 


syringe  (Fig.  148).  If  the  cervical  canal  is  not  so  wide,  a  double-cur- 
rent uterine  tube  (Fig.  149)  should  be  used.  When  it  is  of  import- 
ance to  bathe  the  whole  inside,  cervix  and  body,  it  is  best  to  use  two 


FIG.  148. 


Garrigues'  Single-current  Intra-uterine  Tube. 

single-current  catheters,  a  thinner  afferent  and  a  thicker  efferent. 
The  fluid  then  comes  out  partly  through  the  thick  tube  and  partly 
between  and  around  both. 

The  patient  is  placed  on  a  table,  unless  she  is  so  weak  that  it  is 
deemed  better  to  leave  her  in  her  bed,  and  only  move  her  sufficiently 
beyond  one  edge  to  have  a  free  back-flow  from  the  vagina.  The  outer 
leg  is  placed  on  a  chair.  Whether  she  remains  in  bed  or  is  placed  on 
a  table,  a  rubber  sheet  or  oil-cloth  is  pushed  in  under  her  buttocks, 
and  pinned  with  two  pins  so  as  to  form  a  funnel,  the  lower  end  of  which 
opens  into  a  slop-pail.  Intra-uterine  injections  ought  only  to  be 
given  in  the  dorsal  position  in  order  to  avoid  the  entrance  of  the  fluid 
through  a  possibly  dilated  tube  into  the  peritoneal  cavity.  The 
vagina  is  first  disinfected  by  injecting  some  of  the  fluid  and  by  swab- 
bing the  wall  thoroughly  with  large  pieces  of  absorbent  cotton  dipped 
in  the  same.  Cusco's  speculum  is  introduced.  The  intra-uterine  tube 
is  attached  to  the  tubing  of  the  fountain  syringe,  and,  all  air  having 
been  expelled,  is  pushed  up  to  the  fundus  of  the  uterus  while  the 
fluid  is  turned  on.  The  physician  watches  the  flow  all  the  time  to 
make  sure  that  there  is  no  obstruction.  I  use  about  a  quart  for  the 
vagina  and  from  a  pint  to  a  quart  for  the  uterus.  When  the  uterus 
is  deemed  to  be  sufficiently  washed  out,  it  is  squeezed  in  order  to 
remove  all  fluid  from  its  cavity.  Finally,  the  vagina  is  again  douched, 
and  the  perineum  depressed  so  as  to  allow  all  fluid  to  flow  off. 

For  these  injections  I  prefer  creolin  (1  per  cent.),  as  it  is  a  non- 


174  DISEASES  OF  WOMEN. 

poisonous  reliable  disinfectant  and  an  excellent  hemostatic.     Lysol  is 
also  good,  and  has  the  advantage  of  forming  a  nearly  clear  mixture 


FIG.  149. 


Goelet's  Double-current  Intra-uterine  Tube. 


with  water.  I  have  never  seen  any  untoward  symptoms  follow  this 
kind  of  injections. 

If  the  patient  is  anesthetized,  it  is  better  to  dilate  the  cervix,  intro- 
duce a  cervical  speculum  (p.  150),  and  introduce  an  intra-uterine  tube 
through  the  speculum  all  the  way  up  to  the  ftindus. 

Rectal  injections,  enemas,  or  clysters  are  used  for  emptying  the  lower 
part  of  the  bowels,  or  as  a  vehicle  for  medicinal  substances  to  be 
applied  to  the  diseased  mucous  membrane,  or  in  order  to  exercise  an 
influence  on  the  pelvic  organs,  or  to  overcome  an  obstruction  in  the 
intestine,  or  to  mark  the  course  of  the  intestine  (p.  158).  If  the 
object  is  only  to  cause  a  movement  of  the  bowels,  plain  lukewarm 
water  may  be  used,  or  a  teaspoouful  of  salt  may  be  added,  or  soap- 
suds or  an  infusion  of  linseed-meal  (a  tablespoonful  to  a  quart)  may 
be  injected.  In  cases  of  constipation  with  inipaction  of  hard  feces 
the  following  is  an  excellent  enema:  a  teaspoonful  of  inspissated 
ox-gall,  a  tablespoonful  of  glycerin,  a  tablespoonful  of  castor-oil,  and 
a  heaping  teaspoonful  of  salt,  to  a  quart  of  linseed-meal  infusion. 
The  ox-gall  is  stirred  with  the  warmed  glycerin,  the  oil  is  added, 
then  the  flaxseed  tea,  and  finally  the  salt. 

For  tympanites  an  enema  with  a  teaspoonful  of  oil  of  turpentine, 
a  tablespoonful  of  castor-oil,  and  a  quart  of  soap-suds  or  flaxseed  tea 
is  good.  All  these  enemas  are  given  lukewarm. 

In  diseases  of  the  rectum  often  astringents  or  sedatives  are  used  in 
injections.  As  the  fluid  in  these  cases  is  meant  to  be  retained  for 
some  time,  the  amount  should  be  small  (  3j  to  ,liv). 

Large  injections  (1  to  2  quarts)  of  hot  water  (110°  F.)  into  the 
rectum  have  been  recommended  instead  of  vaginal  injections  in 
uterine  and  other  pelvic  disease.1  They  offer  the  advantage  that  the 
hot  water  reaches  a  larger  area  in  the  pelvis,  but  the  aperient  and 
weakening  effect  is  in  most  cases  a  drawback. 

1  J.  E.  Chadwick,  Trans.  Amer.  Gyn.  Soc.,  1880,  vol.  v.  p.  282. 


TREATMENT  IN  GENERAL. 


175 


After  operations  rectal  injections  of  a  pint  of  tepid  water  may  be 
used  to  relieve  thirst.  Similar  injections  of  very  hot  water  may  be 
used  to  combat  collapse  caused  by  loss  of  blood. 

All  rectal  injections  are  best  given  with  the  patient  lying  on  her 
left  side.  Evacuant  enemas  are  preferably  administered  by  means  of 
a  bulb-and-valve-syriuge  (Davidson's),  but  where  it  is  desirable  that 
as  much  water  as  possible  should  enter  the  bowel,  the  fountain-syringe 
used  with  very  little  pressure  is  by  far  better. 

Vesical  injections  are  used  very  much  in  diseases  of  the  bladder. 
The  patient  occupies  the  dorsal  position.  For  large  injections  Reyes's 

FIG.  150. 


Keyes's  Irrigator  for  Bladder. 

irrigator  (Fig.  150)  may  be  used.  It  is  essentially  a  fountain-syringe 
with  a  two-way  stop-cock,  which  allows  alternately  to  fill  and  empty 
the  bladder  simply  by  turning  the  stopcock.  It  may  be  used  with 
any  hard  or  soft  catheter.  Another  good  and  simple  apparatus  for 
washing  out  the  bladder  consists  of  a  catheter,  an  intermediate  piece 
of  rubber  tubing  about  two  feet  long,  and  a  funnel.  The  funnel 
is  held  up  during  injection,  and  is  brought  down  below  the  level 
of  the  bladder  when  we  want  to  empty  it,  thus  establishing  a  si- 
phonage.  Care  should  be  taken  to  let  as  little  air  as  possible 
enter  the  bladder.  Where  shreds  are  to  be  washed  out,  Notfs 
double-current  catheter  (Fig.  151)  with  its  large  eyes  will  be  found 


176 


DISEASES  OF   WOMEN. 


to  answer  a  good  purpose.    For  smaller  injections,  Thompson's  rubber 
bag  with  stopcock  (Fig.  152),  inserted  into  a  soft  catheter  with  hard 


FIG.  151. 


Nott's  Double-current  Catheter. 


rubber  mouth-piece  is  handy.  For  the  injections  is  used  plain 
water,  or  solutions  of  chloride  of  sodium  (1  per  cent.),  salicylic  acid 
(1  per  thousand),  boracic  acid  (3  per  cent.),  tannin  (J  to  1  per  cent.), 


FIG.  152. 


Thompson's  Rubber-bag  with  Stopcock. 


carbolic  acid  (J  per  cent.),  creolin  (J  per  cent.),  permanganate  of  po- 
tassium (^  to  2  per  thousand),  nitrate  of  silver  (2  to  5  per  thousand), 
etc.  The  amount  of  fluid  used  varies  from  half  a  pint  to  a  quart; 
for  small  injections  one  to  four  ounces  are  used.  Generally  the  fluid 
should  be  pleasantly  lukewarm  (95°  F.),  but  as  hemostatic  hot  or  ice- 
water  is  used.  The  irrigation  of  the  bladder  is  repeated  once,  twice, 
or  three  times  a  day. 

Intravenous,  subcutaneous,  or  intraperitoneal  injection  of  a  hot  solu- 
tion of  6  parts  of  chloride  of  sodium  in  1000  parts  of  hot  water  (110° 
to  115°  F.),  or  about  a  flat  teaspoonful  to  a  quart,  is  used  with  great 
benefit  to  counterbalance  loss  of  blood  in  operations.  (See  Uterine 
Fibroids.) 

C.  Curetting. — The  instruments  used  for  scraping  the  inside  of  the 
uterus  have  been  described  in  the  preceding  chapter  (p.  153).  The 
patient  is  placed  on  a  table  arranged  for  infra-uterine  injection  (p.  173). 
As  the  procedure  is  often  protracted  and  painful,  she  ought  to  be 


TREATMENT  IN  GENERAL.  177 

anesthetized.1  The  vagina  and  uterus  are  disinfected  with  creolin 
(p.  173).  The  cervix  is  dilated  (p.  154).  The  condition  of  the  in- 
side of  the  uterus  is  ascertained  by  sound  (p.  152)  or  finger.  The 
index-finger  is  preferable  if  the  cervix  admits  it.  In  introducing  it 
counter-pressure  is  made  on  the  fund  us  with  the  other  hand.  The 
nail  of  the  finger  is  often  used  itself  as  curette.  It  is  safer  than,  but 
not  so  efficient  as,  instruments.  In  gynecological  cases  I  use  the  dor- 
sal position  and  introduce  the  curette  through  disco's  speculum  (p. 
144) ;  or  if  the  patient  is  anesthetized,  I  pull  the  uterus  down  to  the 
vulva  with  a  tenaculum-forceps  while  the  perineum  and  the  posterior 
vaginal  wall  are  being  pulled  back  with  a  single  Sims  speculum.  The 
curette  is  moved  up  and  down  along  the  surfaces  and  edges  and  from 
side  to  side  along  the  fundus.  In  cases  of  incomplete  abortion  I  often 
turn  the  patient  on  her  left  side  and  work  with  the  left  index-finger 
and  the  large  dull  wire  curette  simultaneously.  The  scraping  should 
be  continued  until  everything  is  removed  and  the  inside  of  the  uterus 
is  smooth.  Then  the  patient  is  turned  back  into  the  dorsal  position. 
Finally,  the  uterus  and  vagina  are  again  disinfected,  and  a  tampon  is 
put  in  the  latter  until  the  following  day.  The  hemorrhage  is  not  very 
considerable.  It  is  very  rarely  necessary  to  renew  the  tampon.  On 
changing  it  a  vaginal  injection  with  creolin  or  carbolic  acid  is  given, 
and  after  its  final  removal  twice  a  day  as  long  as  there  is  any  dis- 
charge. The  patient  is  kept  in  bed  for  four  days.  If  there  is  any 
pain,  which  is  an  exception,  an  ice-bag  is  applied  over  the  symphysis 
and  the  patient  is  given  an  opiate. 

Thomas's  dull-wire  curette  being  rather  short  to  be  used  through 
Cusco's  speculum  (he  uses  himself  Sims's  position  and  speculum),  I 
have  had  one  made  that  is  eleven  inches  long.  The  instrument  should 
only  be  used  for  scraping  in  the  direction  from  the  fundus  to  the  os 
and  along  the  fundus.  In  moving  the  curette  up  toward  the  fundus 
great  gentleness  should  be  used,  as  otherwise  the  instrument  may  per- 
forate the  uterus.  If  this  should  happen,  the  beginner  need  not  be 
particularly  alarmed.  It  has  happened  twice  to  me,  and  no  bad  con- 
sequences were  observed,  but  in  such  a  case  it  is  necessary  to  desist 
from  washing  out  the  uterus,  an  omission  which,  of  course,  in  other 
respects  is  undesirable.  The  smaller  the  loop  of  the  curette,  the 
greater  is  the  danger  of  perforation.  We  should,  therefore,  always 
use  as  large  an  instrument  as  will  enter  the  cervix  and  is  in  reason- 
able proportion  to  the  mass  to  be  removed.  In  cases  of  incomplete 
abortion  before  the  end  of  the  second  month,  when  the  large  dull-wire 
curette  does  not  enter,  Recamier's  curette  (Fig.  1 53)  is  sometimes  useful. 

D.  Tamponade. — The  word  tampon  is  French,  and  means  a  small 
mass  of  cotton  or  other  soft  material  which  is  carried  into  a  wound  or 

1  This  applies  to  strictly  gynecological  cases ;  in  cases  of  hemorrhage  due  to  recent 
abortion,  anesthesia  can  be  dispensed  with  except  in  very  nervous  women. 
12 


178  DISEASES  OF  WOMEN. 

cavity  for  the  purpose  of  filling  it,  so  as  to  prevent  hemorrhage,  or 
applying  drugs  to  it,  or  exercising  pressure  on  it.  A  tampon  being 
used  for  so  very  different  purposes,  becomes  a  very  different  thing, 
and  we  will,  therefore,  consider  separately  the  application  of  rnedi- 

FIG.  153. 


R6camier's  Curette. 

cated  pledgets  in  the  vagina,  the  packing  of  the  vagina,  the  hemo- 
static  vaginal  plug,  and  the  tamponade  of  the  uterus. 

Pledgets  in  the  Vagina. — Small  rolls  of  absorbent  cotton,  about 
2J  inches  long  and  1  inch  thick,  with  a  string  of  strong  crochet- 
yarn  fastened  round  the  middle  and  made  long  enough  to  hang  an 
inch  or  two  outside  the  vulva,  are  impregnated  with  some  medicinal 
substance  and  pushed  up  to  the  posterior  vault  of  the  vagina.  They 
are,  as  a  rule,  withdrawn  morning  and  evening,  when  an  injection  is 
made  and  a  new  pledget  put  in.  The  cotton  may  be  impregnated 
with  different  substances.  The  most  generally  useful  and  least  ob- 
jectionable is  pure  glycerin,  which  produces  a  watery  discharge,  re- 
lieves pain,  and  scatters  swelling.  I  have  used  iodine-glycerin  (5  per 
cent.)  and  an  iodoform  ointment, 

Jfy.  lodoformi, 

Balsami  Peruvian!,         ad  3j  ; 
Vaselini,  3j ; 

but  have  always  come  back  to  the  plain  glycerin.  Of  late  years  I 
use  much  ichthyol-glycerin  (5  per  cent.),  which  has  a  special  resolv- 
ing power  and  some  anodyne  effect.  As  an  astringent,  for  instance, 
for  a  spongy  cervix,  tannin-glycerin  (10  per  cent.)  is  very  efficient, 
but,  as  it  stains  the  clothes,  it  is  necessary  to  wear  a  napkin  with  it. 
Others  prefer  boroglyceride  or  sulphate  or  acetate  of  aluminium,  in 
the  proportion  of  3j  to  glycerin  Oj.1 

Packing  of  the  vagina  differs  from  the  application  of  a  pledget,  as 
heretofore  considered,  by  the  combined  action  of  drugs  and  pressure 
in  the  treatment  of  diseases  of  the  uterus,  ovaries,  and  periuteriue 
structures.  The  patient  is  placed  in  the  knee-chest  position,  Sims's 
speculum  is  introduced,  and  the  vagina  is  packed  tightly  with  pledgets 
of  cotton  so  as  to  form  an  inverted  coniform  column,  filling  the  poste- 
rior cul-de-sac  and  resting  on  the  pubic  arch  and  the  perineum  below. 
The  uppermost  pledget,  which  covers  the  cervical  portion  and  part  of 

1  Wiley,  Ned.  Record,  October  8,  1887,  vol.  xxxii.  p.  483. 


TREATMENT  IN  GENERAL.  179 

the  vaginal  roof,  should  be  saturated  with  pure  glycerin.  The  others  are 
rolled  into  cylinders  and  put  in  dry.  The  patient  herself  or  a  nurse 
withdraws  the  tampon  after  thirty-six  hours,  when  a  hot  douche  is 
given.  The  columnizing  is  repeated  two  or  three  times  a  week.1 

By  this  method  adhesions  may  be  lengthened,  cicatrices  stretched, 
exudations  absorbed,  congestion  relieved,  and  the  vagina  lengthened  ; 
but  if  the  parts  are  too  tender  to  stand  the  pressure,  other  methods 
must  first  be  used  to  overcome  the  sensitiveness. 

The  Hemostatic  Vaginal  Plug. — Plugging  of  the  genital  canal  is  one 
of  the  most  potent  remedies  against  hemorrhage.  A  vaginal  plug 
must  be  put  in  in  such  a  way  as  fully  to  distend  the  vagina,  for 
which  often  two  dozen  good-sized  pieces  of  cotton  are  necessary. 
Generally  I  prefer  common  cotton  batting  to  any  other  material. 
The  balls  should  be  soaked  in  a  1  per  cent,  creolin  emulsion  and 
squeezed  dry.  Thus  they  acquire  both  styptic  and  antiseptic  proper- 
ties. The  first  may  also  be  obtained  by  squeezing  them  out  of  an 
alum  solution,  the  latter  by  using  carbolized  water  (1  per  cent.).2 
When  there  is  much  bleeding  from  an  accessible  surface — e.  g.  after 
curetting  a  cancerous  cervix — the  three  or  four  upper  pledgets  which 
immediately  touch  the  cervix  should  be  wrung  out  of  a  mixture  of 
one  part  of  liq.  ferri  chloridi  and  ten  parts  of  water.  The  liquor 
should  never  be  used  undiluted  on  a  tampon.  I  have  seen  it  cause 
deep  ulcers  which  took  weeks  to  heal,  and  the  removal  of  the  tampon 
is  very  painful.  Bichloride  of  mercury  is  not  good  for  tampons,  as 
by  imbibition  with  blood  they  lose  their  antiseptic  properties. 

Instead  of  cotton  batting,  a  roller  bandage,  lampwick  (Foster),  or, 
if  nothing  else  can  be  obtained,  clean  pocket-handkerchiefs,  may  be 
used,  all  of  which  ought  to  be  treated  with  disinfectants.  A  strip  of 
iodoform  gauze  four  finger-breadths  wide  is  good,  and  may  be  made 
more  antiseptic  and  styptic  by  powdering  it  with  equal  parts  of  iodo- 
form and  tannin.  The  iodoform  gauze  acts  at  the  same  time  as  a 
drain,  and  is,  therefore,  particularly  appropriate  in  the  treatment  of 
cancer,  but  on  account  of  the  very  porosity  of  this  material  I  would 
not  rely  on  it  in  severe  hemorrhage. 

The  vaginal  tampon  is  best  applied  in  Sims's  position  and  with 
Sims's  speculum.  The  rectum  and  bladder  having  been  emptied,  the 
first  pledgets  are  placed  around  the  cervix  and  then  over  it,  and  the 
same  principle  should  be  followed  if  a  continuous  long  strip  of  some 
kind  is  used.  Whatever  we  use  should  be  evenly  and  tightly  put  in 
with  a  strong  pair  of  dressing-forceps  until  the  vagina  is  filled  all 
the  way  down  to  the  entrance  (but  not  the  vulva).  If  the  patient 

1  Nathan  Bozemann,  "  The  Value  of  Graduated  Pressure  in  the  Treatment  of 
Diseases  of  the  Vagina,  Uterus,  Ovaries,  and  other  Appendages,"  Atlanta  Medical 
Register,  January,  1883. 

2  A  stronger  solution  takes  off  the  whole  epithelium. 


180  DISEASES  OF   WOMEN. 

cannot  pass  her  urine  spontaneously,  it  must  be  drawn  four  times  a 
day,  but  that  is  an  exception.  The  tampon  should  be  removed  and, 
if  necessary,  renewed  within  twenty-four  hours,  except  if  made  of 
iodoform  gauze,  when  it  may  stay  in  for  five  or  six  days  if  necessary. 
In  exceptional  cases  of  severe  hemorrhage  the  vulva,  too,  must  be 
filled,  and  a  tightly-rolled  towel  placed  on  the  perineum  and  held 
tightly  pressed  against  it  by  means  of  a  bandage  which  surrounds  the 
pelvis,  and  from  which  one  or  preferably  two  tails  are  carried  between 
the  thighs  and  fastened  in  front  to  the  band  surrounding  the  pelvis. 

If  a  strip  of  some  substance  has  been  used,  all  that  is  necessary 
for  its  removal  is  to  pull  on  the  lower  end,  which  should  be  left 
hanging  just  outside  the  vulva.  If  cotton  pledgets  have  been  em- 
ployed, the  patient  is  again  placed  in  Sims's  position,  Sims's  speculum 
is  introduced  a  short  distance,  some  pledgets  are  pulled  out  with  the 
dressing- forceps,  and  the  speculum  is  gradually  pushed  farther  in 
until  the  whole  tampon  has  been  removed.  Then  the  patient  is 
turned  on  her  back  and  given  a  vaginal  injection  with  creolin.1 

Tamponade  of  Uterus. — For  the  uterine  cavity  only  iodoform  gauze 
should  be  used.  This  method  is  not  only  used  to  great  advantage  in 
post-partum  hemorrhage,  which  does  not  concern  us  here,  but  like- 
wise for  many  gynecological  conditions,  either  as  hemostatic  or  for 
applying  medicinal  powders  or  fluids  to  the  mucous  membrane  of  the 
womb,  or  for  causing  changes  in  the  structure  of  the  uterine  muscular 


FIG.  154. 


Garrigues'  Curved  Intra-uterine  Packing-forceps. 

tissue,  especially  in  chronic  endometritis  and  metritis,  and  even  in  the 
hope  of  causing  depletion  from  inflamed  tubes.  It  is  used  both  in  the 
cervix  and  in  the  body  of  the  womb.  Even  a  nulliparous  uterus  will 
admit  a  strip  of  gauze  8  inches  long  and  £  inch  wide.  On  account 
of  the  antiseptic  properties  of  the  iodoform  the  intra-uterine  tampon 
may  be  left  undisturbed  for  five  or  six  days. 

I  have  constructed  a  forceps  for  its  application  through  an  undi- 

1  To  attach  a  string  to  each  pledget  does  not  facilitate  their  removal.  The  so-called 
kite-tail,  made  by  tying  all  the  pledgets  to  one  string,  is  indeed  more  easy  to  remove, 
but  more  troublesome  to  put  in. 


TREATMENT  IN   GENERAL.  181 

lated  cervix  (Fig;.  154).1  But,  as  a  rule,  the  cervix  should  be  pulled 
down  to  the  entrance  of  the  vagina  with  a  bullet-forceps  and  dilated 
with  Hanks'  dilators.  The  uterus  should  be  curetted  and  washed 
out  through  Barrage's  cervical  speculum  (Fig.  126,  p.  150),  with  a 
single-current  tube  (Fig.  148,  p.  173)  reaching  to  the  fundus,  and  the 
uterine  cavity  packed  with  a  strip  of  iodoform  gauze  4  centimeters 
wide  and  folded  so  as  to  form  four  layers  1  centimeter  wide,  the  end 
of  which  strip  is  left  hanging  in  the  vagina,  and  a  pad  of  the  same 
material  is  placed  in  the  vagina.  The  gauze  is  pushed  through  the 
speculum  by  means  of  a  straight  forceps  (Fig.  155). 

FIG.  155. 


Garrigues'  Straight  Intra-uterine  Packing-forceps. 


Abdominal  Tampon. — The  iodoform-gauze  tampon  is  even  used  in 
the  abdominal  cavity.  Sometimes  there  may  be  considerable  oozing 
of  blood  after  a  laparotomy,  which  does  not  yield  to  hot  water  poured 
into  the  peritoneal  cavity.  In  such  cases  the  hemorrhage  is  some- 
times checked  effectually  by  packing  the  pelvis  with  iodoform  gauze 
through  the  abdominal  wound.  The  end  is  left  hanging  from  the 
lower  end  of  the  wound,  and  in  closing  the  same  one  or  two  of  the 
lowest  sutures  are  left  untied  till  the  next  day  and  the  removal  of  the 
tampon.  In  the  mean  time  sufficient  adhesive  matter  has  been  formed 
to  shut  off  the  abdominal  cavity  from  that  part  where  the  tampon 
was  put  in,  but  the  adhesions  are,  of  course,  weak,  and  it  would  be 
too  great  a  risk  to  use  injections  through  the  wound.  It  is  a  good 
plan  first  to  introduce  the  centre  of  a  large  square  piece  of  iodoform 
gauze  and  make  a  pouch  of  it,  which  is  subsequently  filled  with  long 
strips  of  gauze  the  ends  of  which  remain  outside  (Mickulicz's  method). 
This  tampon  acts  not  only  as  a  plug,  but  at  the  same  time,  on 
account  of  the  porosity  of  the  gauze,  as  a  drain.  Sometimes  it  is 
necessary  to  combine  the  intra-abdominal  tampon  with  one  in  the 
vagina.  In  order  to  remove  the  abdominal  tampon,  each  strip  is 
pulled  out  separately  and  finally  the  surrounding  gauze  by  pulling 
on  a  strong  silk  thread  inserted  for  that  purpose  in  its  center  before 
introducing  it. 

E.  ffemostasis. — Besides  the  hemostatic  tampon,  of  which  we  have 
just  spoken,  other  means  of  preventing  or  checking  hemorrhage  are 
available:  hot  water,  styptics,  cauterization,  ligature,  suture,  and  ford- 
pressure. 

1  Amer.  Jour.  Obst.,  vol.  xxv.  No.  1,  January,  1892. 


182  DISEASES  OF  WOMEN. 

Hot  water  is  used  in  vaginal  injection  (p.  171  et  seq.}  before  opera- 
tions in  order  to  diminish  bleeding  during  them  (T.  A.  Emmet).  It 
is  also  used  to  check  hemorrhage  during  operations.  Thus  a  stream 
of  some  hot  antiseptic  solution  may  be  kept  continually  flowing  over 
the  field  of  operation l  or  may  occasionally  be  directed  against  the 
bleeding  surface.  At  the  end  of  laparotomy  hot  water  is  often  poured 
by  the  pitcher  or  through  a  finger-thick  glass  tube  right  into  the  peri- 
toneal cavity.  Hot-water  injections  are  also  used  as  a  hemostatic 
independently  of  operations,  both  in  the  vagina  and  in  the  uterus 
(pp.  172, 173). 

Styptics,  especially  alum,  tannin,  and  chloride,  persulphate  or  sub- 
sulphate  of  iron  (Monsel's  solution),  are  used  as  applications  (p.  170), 
on  tampons  (p.  177),  or  in  injections  (p.  172).  The  undiluted  liq.  ferri 
chloridi  or  subsulphatis  may  be  applied  with  cotton  to  small  bleeding 
surfaces.  Diluted  with  10  parts  of  water,  it  may  be  used  in  injections 
or  left  in  on  a  tampon.  A  very  convenient  way  of  using  styptics  on 
small  wounds  is  in  the  shape  of  dry  styptic  cotton  as  sold  in  the  drug- 
stores. 

Cauterization  is  an  excellent  hemostatic  and,  at  the  same  time,  an 
antiseptic,  but  as  it  leaves  an  eschar,  it  can,  as  little  as  styptics,  be 
used  where  healing  by  first  intention  is  aimed  at.  The  dry  heat  of 
the  actual  cautery  is  so  powerful  a  hemostatic  that  it  may  even  be 
used  to  sever  the  pedicle  of  an  ovarian  tumor  without  using  any 
ligature.  A  very  convenient  apparatus  is  Paquelin's  thermo-cautery 
(Fig.  156),  in  which  a  tip  of  platinum  may  be  kept  at  different  de- 
grees of  heat  by  a  more  or  less  abundant  supply  of  benzine  vapor. 

Independently  of  its  hemostatic  effect,  cauterization  is  often  used 
as  an  antiseptic  to  sear  a  wound  surface,  and  thus  make  it  impene- 
trable to  bacilli.  Thus,  some  use  it  on  the  stumps  left  after  removal 
of  the  ovaries  or  the  uterus. 

Cauterization  by  means  of  the  gahano-cautery  will  be  described 
under  Electric  Treatment. 

Ligature. — Spurting  arteries,  or  more  rarely  bleeding  veins,  may 
be  ligated  with  silk  or  catgut,  according  to  the  general  rules  of  sur- 
gery, but  in  gynecological  practice  we  are  oftener  than  in  other  de- 
partments obliged  to  tie,  not  the  isolated  bleeding  vessel,  but  a  more 
or  less  considerable  mass  of  the  surrounding  tissue  with  it  (mass  liga- 
ture). Arteries  may  be  tied  where  they  are  severed  or  in  continuity. 

Ligature  of  the  Uterine  Artery. — The  uterine  artery  may  be  tied 
from  the  vagina.  According  to  Martin,  the  patient  is  placed  in  the 
dorsal  posture  with  raised  knees.  A  broad,  short,  and  flat  specu- 
lum is  introduced.  The  operator,  sitting  in  front  of  the  table, 
tries  to  locate  the  artery  by  its  pulsation.  The  cervix  is  pulled  well 
over  to  one  side  with  a  volsella.  A  middle-sized,  strong,  curved 

1  Geo.  Engelmann  of  Boston,  Trans.  Amer.  Med.  Assoc.,  1885. 


TREATMENT  IN  GENERAL.  183 

needle  is  introduced  into  the  anterior  part  of  the  fornix  of  the  vagina, 
a  finger-breadth  [?]  from  the  cervix  and  on  a  line  with  its  anterior 
circumference.  The  needle  is  carried  deep  in,  and  pushed  out  on  a 
line  with  the  posterior  wall  of  the  cervix.  Next,  the  ligature  is  tied 
very  tightly.  If  needed,  the  same  may  be  done  on  the  other  side.1 

FIG.  156. 


Thermo-cautery. 


There  is  danger  of  comprising  the  ureter  in  the  ligature ;  and,  since 
the  ureter  lies  about  half  an  inch  outside  of  the  cervix  (p.  81),  a  fin- 
ger-breadth, as  advised  by  Martin,  would  be  a  particularly  dangerous 
distance.  In  the  opinion  of  the  writer,  one-third  of  an  inch  is  the 
proper  distance. 

Fritsch 2  is  opposed  to  methods  by  which  the  uterine  artery  is  tied 
by  means  of  a  mass  ligature  applied  through  the  vaginal  roof.  He 
says  by  so  doing  we  do  not  know  what  we  tie,  and  even  if  the  uterine 
artery  is  included  in  the  ligature,  it  is  not  sure  that  it  is  made  imper- 
vious. He  makes  an  incision  an  inch  and  a  quarter  long  in  the  pos- 
terior roof  of  the  vagina  on  the  right  and  left  sides.  This  incision 
divides,  as  a  rule,  first  the  two  vaginal  branches.  Next  he  cuts  deeper 
until  he  has  severed  the  uterine  artery,  which  is  then  seized  and  tied 
or  surrounded  by  a  mass  ligature.  Then  the  same  is  done  on  the  other 
side.  The  wounds  are  filled  with  iodoform  gauze  in  order  to  prevent 
rapid  healing  and  the  formation  of  a  collateral  circulation. 

The  safest  procedure  is  to  make  a  transverse  incision  in  front  of  the 
cervix,  just  below  the  bladder,  separate  this  from  the  uterus,  carry  the 
bladder  and  ureters  forward  with  a  retractor,  ligate  the  artery  by  carry- 
ing a  silk  ligature  around  it  with  Schroeder's  or  Folk's  needle  (see 
Uterine  Fibroids)  from  the  front  backward,  cut  the  ligature  short, 
and  close  the  vagina  with  a  running  suture  of  catgut. 

The  uterine  artery  may  also  be  tied  from  the  abdominal  cavity  after 
performing  laparotomy  (see  Uterine  Fibroids). 

Ligature  of  the  Internal  Pudic  Artery. — As  a  rule,  this  artery 
should  be  cut  down  upon  where  it  bleeds  and  both  ends  tied,  but  it 

1  A.  Martin,  Pathologic  und  Therapie  der  Frauenkrankheiten,  Leipzig,  1885,  p.  22. 

2  H.  Fritsch,  Billroth  und  Luecke,  Handb.  der  Frauenkrankheiten,  Stuttgart,  1885. 
vol.  i.  p.  949. 


184 


DISEASES  OF  WOMEN. 


FIG.  157. 


may  also  be  tied  in  continuity  by  cutting  through  the  skin  and  fascia 
in  an  oblique  line  running  downward  and  outward  a  little  above  the 
spine  of  the  ischium,  separating  the  fibers  of  the  glutens  maximus, 
holding  them  apart  with  retractors,  and  tearing  the  deep  fascia. 

Sometimes  sutures  are  used  for  hemostatic  purposes — e.  g.  a  run- 
ning catgut  suture  may  be  put  over  a  bleeding  tear  in  the  broad  liga- 
ment; or  an  artery  imbedded  in  tissue  may  be  made  to  stop  bleeding 
by  passing  a  needle  with  thread  under  its  course  and  tying ;  or  a 
bleeding  surface  of  the  abdominal  wall  may  be 
excluded  from  the  abdominal  cavity  by  folding 
the  wall,  so  as  to  press  one-half  of  the  bleeding 
surface  against  the  other,  and  put  sutures 
through  from  side  to  side  as  in  a  mattress  (mat- 
tress suture).  These  sutures  may  be  made  more 
efficacious  by  using  quills,  a  couple  of  lead-pen- 
cils or  pen-holders  serving  as  such. 

Forcipressure. — Much  time  is  saved  by  sub- 
stituting a  temporary  strong  pressure  with  Koe- 
berle"'s  clamp  (Fig.  157),  a  kind  of  artery- 
forceps  with  catch  that  has  been  modified  by 
many  other  operators,  and  therefore  goes  under 
different  names  (Plan's,  Spencer  Wells's,  Tait's, 
etc.).  When  made  of  proper  size  and  left  for 
twenty-four  hours,  such  forceps  may  be  made  to 
secure  even  the  uterine  and  the  ovarian  arteries 
in  the  extirpation  of  the  uterus ;  but  in  most 
operations  small  clamps,  five  or  six  inches  long, 
are  used  temporarily,  and  removed  toward  the 
end  of  the  operation  when  the  bleeding  is  stopped. 
If,  exceptionally,  a  vessel  yet  bleeds,  it  may,  of 
course,  be  seized  again  with  the  forceps  and  secured  with  a  ligature. 
F.  Dilatation  and  G.  drainage  are  so  intimately  connected  that  we 
will  treat  of  them  together.  In  regard  to  dilatation  of  the  cervix 
the  reader  is  referred  to  what  has  been  said  on  the  subject  in  the 
chapter  on  Examination  (pp.  154-156). 

Dr.  Outerbridge  of  New  York  has  constructed  an  ingenious  instru- 
ment for  permanent  dilatation  of  the  cervix  and  drainage  of  the 
uterus.  It  consists  of  a  silver-  or  gold-plated  steel  wire  (Fig.  158), 
made  so  as  to  form  an  anterior  and  posterior  blade,  with  a  slight 
eversion  at  one  end  and  bent  at  right  angles  at  the  other.  It  is  self- 
retaining,  and  varies  in  length  and  curvature.  For  its  introduction 
the  patient  may  be  in  Sims's  or  in  the  dorsal  position.  The  univalve 
or  bivalve  speculum  is  introduced,  the  cervix  steadied  with-  a  tenacu- 
lum,  and  the  dilator  put  into  the  grasp  of  a  carrier  made  for  the  pur- 
pose (Fig.  1 59).  It  consists  of  a  fork  with  a  movable  ball  and  spiral 


Koeberl6's  Artery- 
Clamp. 


TREATMENT  IN  GENERAL. 


185 


spring  sliding  up  and  down  a  metal  rod  with  handle.     The  dilator  is 
introduced   five  or  six  days  before  expected  menstruation,   left  in 


FIG.  159. 


Outerbridge's  Permanent  Dilator  of  Cervix. 

during,  and  at  least  from  five  to  eight  days 
after  the  same,  unless  conception  takes  place 
and  menstruation  does  not  come  on.  The  in- 
strument may  be  removed  with  a  finger  or  by 
means  of  speculum  and  teuaculum  or  a  blunt 
hook.1 

Sometimes  a  perforated  glass  or  hard-rubber 
stem  is  introduced  into  the  uterus,  and  on  the 
same  principle  I  have  had  a  glass  vaginal  plug 
made  with  an  opening  at  the  top. 

Sometimes  an  opening  is  made  with  knife  or 
trocar  in  the  vaginal  roof,  behind  the  uterus, 
with  or  without  laparotomy.     This  opening  is 
enlarged  by  means  of  a  diverging  uterine  di- 
lator and  a  soft-rubber  drainage-tube  inserted. 
The  same  may  be  carried  through  the  abdom- 
inal wound.     If  it  is  only  introduced  through 
an  opening  in  the  vagina  into  a  space  shut  off  from  the  peritoneal 
cavity,  the  drain  should  have 
a  T  shape,  the  upper  bar  of 
the  T  serving  as  wings  to  re- 
tain the  tube  in  situ. 

In  laparotomies  often  a  glass 
tube  (Fig.  160)  is  left  leading 

from  the   bottom  of  Douglas's  Abdominal  Glass  Drainage-tube. 

pouch  or  of  a  cyst  which  can- 
not be  entirely  removed  to  the  lower  end  of  the  wound,  where  it  i* 
1  P.  E.  Outerbridge,  Med.  Record,  April  20,  1889,  vol.  xxxv.  p.  430. 


Carrier  for  Outerbridge's 
Dilator. 


FIG.  160. 


186  DISEASES  OF   WOMEN. 

held,  between  the  lips  of  the  incision,  by  the  sutures.  The  tube  is 
closed  with  a  stopper  of  iodoform  gauze,  and  the  accumulating  fluid 
pumped  out  at  short  intervals — in  the  beginning  every  hour — by  means 
of  a  small  glass  syringe  and  attached  rubber  tube.  It  is  still  better  to 
utilize  the  capillarity  of  iodoform  gauze  and  fill  the  tube  loosely  with 
a  strip  of  this  material,  through  which  the  fluid  will  trickle  out. 

Great  diversity  of  opinion  obtains  among  leading  gynecologists  as 
to  the  frequency  with  which  abdominal  drainage  should  be  used  and 
the  length  of  time,  the  tube  should  be  left  in.  The  more  strictly 
antisepsis  is  carried  out  during  operations  the  less  drainage  becomes 
necessary,  and  the  absorbent  power  of  the  peritoneum  may  to  a  great 
extent  be  relied  upon  to  remove  blood  and  serum  from  the  abdominal 
cavity. 

We  have  already  spoken  of  the  use  of  iodoform  gauze  for  drainage 
of  the  uterus  and  the  abdomen  (pp.  179-181).  For  further  particulars, 
see  Ovariotomy. 

H.  Bloodletting. — Leeches,  from  two  to  four  in  number,  may  be 
applied  through  Fergusson's  speculum  to  the  vaginal  portion.  In 
order  to  prevent  them  from  entering  the  uterus  a  small  cotton  plug 
should  be  placed  in  the  cervical  canal.  This  method  is  little  used  here. 

The  artificial  leech  may  be  substituted  with  advantage  (Fig.  161). 

FIG.  161. 


Reese's  Uterine  Leech.  It  consists  of  a  glass  cylinder  with  scale.  By  pressure  on  the  plate, 
A,  a  lance-shaped  knife  is  pushed  into  the  tissue  of  the  cervix  to  a  depth  regulated  by 
screwing  the  disc,  I.  along  the  piston,  B,  and  then  withdrawn.  By  pulling  the  piston  out 
a  vacuum  is  created,  into  which  the  blood  enters.  The  metal  fitting,  C,  can  be  unscrewed, 
so  as  to  allow  the  removal  of  the  piston  and  the  cleaning  of  the  tube. 

Scarification. — In  most  cases  no  sucking  apparatus  is  needed.     A 
small  spear  (Fig.  162)  is  pushed  to  the  depth  of  three-quarters  of  an 

FIG.  162. 


Buttle's  Uterine  Scarificator. 


inch  into  the  vaginal  portion  in  three  or  four  places,  and  from  half 
an  ounce  to  two  ounces  of  blood  are  withdrawn  twice  a  week.  The 
posterior  lip  is  less  sensitive  than  the  anterior.  If  the  flow  does  not 
stop  of  itself,  the  small  openings  are  pressed  together  with  a  pledget 
of  cotton  dipped  into  cold  water,  or  if  that  does  not  suffice  liquor 
ferri  is  applied  or  a  hot  douche  is  administered. 


TREATMENT  IN  GENERAL. 


187 


FIG.  163. 


Bloodletting  is  a  very  valuable  remedy  in  cases  of  chronic  conges- 
tion, not  only  of  the  uterus,  but  also  of  other  pelvic  organs.  It  has 
great  power  to  relieve  pain. 

I.  Heat  and  Cold. — We  have  spoken  above  of  hot,  lukewarm,  and 
cold  injections  (pp.  171-176  and  182).  Heat  is  applied  to  the 
abdomen  in  the  shape  of  a  flaxseed-meal  poultice  or  a  rubber  bag 
filled  with  hot  water  or  a  double  sheet  of  flannel  wrung  out  of  hot 
water.  Sometimes  the  anodyne  effect  of  such  a  stupe  or  fomentation 
is  increased  by  sprinkling  it  with  oil  of  turpentine  or  laudanum. 
Poultices  or  a  small  rubber  bag  with  hot  water  may  also  be  used  in 
the  vagina. 

In  acute  inflammations  an  ice-bag  or  a  coil  with  running  ice-water 
is  a  more  expeditious  remedy,  and  checks  in  most  cases  the  pain  more 
efficaciously.  Four  layers  of  muslin  should  be  inserted  between  the 
ice-bag  and  the  skin  in  order  to  avoid  local  freezing. 

When  the  acute  stage  is  passed,  Priessnitz's  compress — i.  e.  a  towel 
wrung  out  of  cold  water  and  covered  with  some  waterproof  material 
and  held  in  place  with  a  flannel  binder — is  preferable  to  both  hot  and 
cold  applications.  It  is  changed  every  six  hours  and  becomes  warm 
in  a  few  minutes.  This  change  from  cold  to  heat  is 
a  powerful  absorbent. 

A  great  variety  of  baths  may  be  used  as  valuable 
adjuvants  in  gynecological  diseases.  A  tepid  general 
bath,  of  a  temperature  slightly  below  blood-heat, 
taken  for  fifteen  or  twenty  minutes  twice  a  week, 
keeps  not  only  the  skin  in  good  order,  but  has  a 
marked  soothing  influence  on  irritated  nerves.  Sitz- 
baths  of  similar  temperature  may  be  taken  for  ten 
minutes  once  a  day.  The  effect  on  the  pelvic  organs 
may  be  enhanced  by  the  use  of  a  bath-speculum  (Fig. 
163),  which  is  introduced  into  the  vagina  and  allows 
the  water  to  fill  the  same. 

Turkish  and  Russian  baths  may  sometimes  be 
substituted  for  warm  baths,  but  are  often  too  irri- 
tating or  too  fatiguing.  An  artificial  steam-bath  may 
be  improvised  by  placing  an  alcohol  lamp  under  a 
chair  and  an  open  umbrella  partly  over  the  chair 
and  partly  over  the  patient  lying  in  bed,  and  cover- 
ing all  well  with  blankets  and  waterproofs.  If  the 
patient  is  well  enough,  she  may  sit  on  the  chair  cov- 
ered with  a  waterproof.  Perspiration  may  also  be  induced  by  the 
hot  pack.  The  patient  is  wrapped  up  tightly  to  the  neck  in  a  blanket 
wrung  out  of  hot  water,  and  covered  with  several  layers  of  dry 
blankets.  Perspiration  should  not  be  allowed  longer  than  from  half 
an  hour  to  two  hours. 


Bath-speculum. 


188  DISEASES  OF  WOMEN. 

Sea-baths  are  often  very  beneficial  as  a  nerve  tonic  and  to  check  a 
disposition  to  hemorrhage  and  leucorrhea.  A  complete  hydrothera- 
peutic  treatment  may  also  do  good.  On  a  smaller  scale  cold  water 
may  be  used  to  great  advantage  in  the  shape  of  shower-baths,  sponge- 
baths,  the  wet  sheet,  or  towel-baths.  For  a  sponge-bath  the  patient 
stands  in  a  tub  and  has  a  pailful  of  cold  water  standing  at  her  side — 
the  contents  of  which  she  presses  all  over  her  body  with  a  large  sponge. 

For  a  sheet-bath  a  sheet  is  dipped  into  a  pail  of  cold  water  and 
thrown  from  behind  over  the  patient,  who  is  rubbed  with  it  for  sev- 
eral minutes  all  over  the  body.  Thereafter  the  wet  sheet  is  exchanged 
for  a  dry  warm  one  and  the  rubbing  repeated  until  she  is  dry  all  over. 

The  towel-bath  is  less  powerful,  but  by  no  means  without  effect,  in 
keeping  the  skin  in  order,  strengthening  the  nerves,  and  brightening 
the  mind.  It  has  the  advantage  that  no  help  is  needed  for  its  admin- 
istration. All  that  is  required  is  three  Turkish  towels  and  a  large 
basinful  of  cold  water.  The  patient  immerses  one  of  the  towels  in 
the  water,  presses  it  a  little,  and  washes  the  upper  half  of  her  body 
with  it.  Then  she  dries  herself  with  the  two  other  towels,  and  finally 
she  repeats  the  procedure  on  the  lower  half  of  the  body,  except  the 
feet,  which  in  most  people  are  treated  to  greater  advantage  with  warm 
foot-baths. 

Some  European  springs  enjoy  a  particular  reputation  for  their  sup- 
posed effect  on  female  complaints,  such  as  Franzeusbad  and  Marien- 
bad  in  Austria,  Ems  and  Kreuznach  in  Germany,  and  Plombieres  in 
France ;  but  it  would  be  a  grave  mistake  to  think  that  any  watering- 
place  can  be  more  than  an  adjuvant  in  the  proper  treatment  of  diseases 
of  women. 

J.  Counter-irritation. — Tincture  of  iodine  is  often  painted  once  a 
day  on  the  skin  over  a  swelling  in  the  deeper  parts.  When  the  epi- 
dermis is  hardened  a  little,  it  is  well,  in  order  to  avoid  cracking,  to 
cover  it  with  a  compress  soaked  in  the  following  wash  : 

I^j.  Acid,  cartel,  TTLxl ; 

Glycerini,  §ss ; 

Aquse,  q.  s.  ad  §iv. 

This  allows  one  to  continue  the  use  of  the  iodine  indefinitely. 
(Compare  p.  170.) 

Spanish  fly  blisters  are  sometimes  used  on  the  abdomen  to  combat 
inflammation  in  the  deeper  parts.  A  large  blister  is  a  painful  remedy, 
and  it  has  appeared  doubtful  to  me  if  it  is  any  better  than  other  means ; 
but  half  a  dozen  small  blisters,  2—4  square  inches,  one  of  which  is  put 
on  every  evening,  often  relieve  pain  in  chronic  cases. 

K.  Tapping  and  Aspiration. — The  difference  between  these  two 
operations  is  only  that  in  simple  tapping  a  fluid  is  given  outlet 
through  the  canula  of  a  trocar  by  pressure  from  behind,  and  in  aspi- 


TREATMENT  IN  GENERAL. 


189 


ration  by  forming  a  vacuum  in  front ;  but  on  account  of  the  greater 
efficacy  of  the  latter  method  a  smaller  trocar,  or  even  a  needle,  may 
be  used  instead  of  the  large  trocar  used  in  simple  tapping.  The 
object  is  to  remove  a  fluid  collected  in  a  normal  cavity  or  a  cyst. 
Tapping  is  used  much  less  now-a-days  as  a  separate  and  complete 
gynecological  operation  than  a  decade  or  two  ago.  Tumors  are  sel- 
dom tapped,  the  more  radical  operation  of  removal  being  preferred  ; 
but  ascitic  fluid  has  often  to  be  evacuated  by  tapping.  Tapping  is 
used  during  ovariotomy  to  diminish  the  cyst,  and  aspiration  is  often 
used  as  part  of  a  more  comprehensive  operation — e.  g.  in  removing  a 
pyosalpinx  or  opening  a  pelvic  abscess.  Aspiration  through  the  vagi- 
nal roof  is  used  to  remove  encysted  peritonitic  exudation  or  a  collec- 
tion of  pus  in  the  parametrium.  Straight  and  curved,  fine  and  large, 
trocars  or  needles  may  be  needed.  We  have  already  spoken  of  the 
use  of  the  aspirator  for  diagnostic  purposes  (p.  1 59). 

A  patient  who  is  going  to  be  tapped  through  the  abdominal  wall 
should  sit  on  a  chair  or  lie  on  her  side  with  the  abdomen  turned  to- 
ward the  operator.  The  abdomen  should  be  surrounded  above  and 
below  the  point  selected  for  the  operation  with  a  sheet,  the  ends  of 
which  are  crossed  in  front  and  pulled  upon  during  evacuation.  The 
object  thereof  is  not  only  to  produce  the  necessary  pressure  for  the 
evacuation,  but  to  avoid  a  sudden  suction  of  blood  to  the  abdominal 
viscera,  which  might  cause  syncope.  A  quarter  of  a  grain  of  cocaine 
should  be  injected  with  a  hypodermic  syringe  into  the  skin  at  the 
place  selected,  which,  as  a  rule,  should  be  in  the  mesial  line,  midway 
between  the  symphysis  and  the  umbilicus.  Full  antiseptic  precau- 
tions should  be  used.  The  bladder  should  be  emptied  with  the 
catheter.  The  trocar  is  thrust  in,  the  stylet  withdrawn,  and  the  fluid 

FIG.  164. 


Trocar,  composed  of  canula  with  cap,  pointed  stylet,  and  blunt  staff. 


directed  into  a  pail  placed  on  the  floor.     When  all  has  been  removed, 
the  abdominal  wall  is  lifted  in  a  fold  around  the  canula,  the  latter 


190  DISEASES  OF   WOMEN. 

is  withdrawn,  the  opening  is  compressed  from  side  to  side,  and  a  piece 
of  rubber  adhesive  plaster  placed  over  it. 

In  the  vagina  only  the  aspirator  should  be  used.  So  far  as  possible, 
the  puncture  should  be  made  behind  the  uterus.  In  front  is  the 
bladder  and  to  the  sides  are  the  uterine  artery  and  the  ureter.  The 
latter  organs  may,  however,  sometimes  be  felt  and  avoided. 

Tapping  has  occasionally  proved  fatal  by  lesion  of  a  blood-vessel 
in  the  abdomen.  Septicemia  may  be  avoided  by  antiseptic  precau- 
tions. 

Sometimes  the  canula  is  left  in  as  a  drainage-tube,  and  has  for  that 
purpose  two  eyes  for  the  insertion  of  cords  or  wire.  The  puncture 
may  be  followed  by  incision  or  dilatation ;  then  the  pointed  stylet 
is  withdrawn,  and  a  blunt  guide  with  a  longitudinal  furrow  sub- 
stituted. The  canula  is  withdrawn  and  a  knife  is  slid  along  the  fur- 
row in  the  guide  (Fig.  164). 

L.  Abdominal  Belts. — An  elastic  abdominal  belt  (Fig.  165)  is  often 

FIG.  165. 


Abdominal  Belt. 

useful,  especially  in  fat  women,  to  take  off  some  of  the  pressure  on 
the  pelvic  organs,  and  is  used  during  the  first  year  after  laparotomy 
to  take  off  the  strain  on  the  cicatrix. 

When  a  special  pressure  above  the  symphysis  is  required,  an  ab- 
dominal supporter,  with  a  solid  hypogastric  pad,  is  used  (Fig.  166). 

M.  Massage. — Certain  manipulations  inside  of  the  pelvis  and 
through  the  abdominal  walls  constitute  a  valuable  mode  of  treatment 
in  many  diseases  of  women,  especially  chronic  metritis,  cellulitis, 
peritonic  exudations,  adhesions,  hematoma,  and  oophoritis.  Often  a 
general  massage  of  other  parts  of  the  body  or  the  whole  body  is 
added.  In  this  way  exudations,  infiltrations,  hypertrophies,  and 
adhesions  are  made  to  disappear,  weak  ligaments  and  muscles 
strengthened,  and  displaced  organs  brought  back  and  kept  in  their 
normal  position.  The  procedures  being  rather  painful,  there  is  no 
danger  of  causing  sexual  excitement.  The  manipulations  are  quite 
complicated,  have  to  be  adapted  to  the  special  abnormal  conditions 


TREATMENT  IN  GENERAL.  191 

obtaining,  and  can  hardly  be  learned  except  by  seeing  them  carried 
out  by  an  expert.  Unfortunately,  this  treatment  requires  so  long  sit- 
tings l  that  a  gynecologist  or  general  practitioner  will  hardly  find 
time  to  use  it  himself,  and,  on  the  other  hand,  such  fine  diagnosis  is 
necessary  that  nobody  who  has  not  a  large  experience  in  abdominal 
examinations  can  be  entrusted  with  it.2  If  blood  or  pus  has 
accumulated  in  the  Fallopian  tube,  massage  is  counterindicated, 
as  there  is  danger  of  the  fluid  being  pressed  into  the  peritoneal 
cavity. 

FIG.  166. 


Fitch's  Abdominal  Supporter. 

N.  Gymnastics. — Gymnastic  movements,  active  and  passive,  are 
sometimes  a  direct  cure  for  certain  diseases,  perhaps  even  the  best  of 
all — e.  g.  Thure  Brandt's s  wonderful  cure  for  procidentia  uteri. 

In  other  cases  the  Swedish  movement  cure  may  be  a  valuable  adju- 
vant, combined  with  other  methods,  and  even  common  gymnastic  ex- 
ercises, if  not  too  violent,  are  not  only  an  excellent  preventive  of 

1  Up  to  three-quarters  of  an  hour !     The  length  of  the  sittings  is,  however,  par- 
tially counterbalanced  by  the  great  efficacy  of  the  treatment,  which  often  leads  to 
a  cure  in  a  short  time. 

2  The  limits  of  this  work  forbid  me  even  to  give  an  outline  of  the  different 
manipulations  used  in  massage.     Those  interested  in  it  are  referred  to  the  paper  by 
A.  Reeves  Jackson  of  Chicago,  on  "  Uterine  Massage  as  a  Means  of  Treating  certain 
Forms  of  Enlargement  of  the  Womb,"  Trans.  Amer.  Gyn.  Soc.,  1880,  vol.  v.  p.  80  ;  to 
that  by  H.  J.  Boldt  of  New  York,  on  the  "  Manual  Treatment  in  Gynecology," 
Amer.  Jour.  Obst.,  June,  1887,  vol.  xxii.  p.  579 ;  to  that  by  H.  N.  Vineberg  on  "  The 
Treatment  of  Ketrodisplaeements  of  the  Uterus  with  Adhesions  by  Brandt's  Method," 
N.  Y.  Med.  Record,  July  11,  1891;  and  to  Profanter's  pamphlet,  Die  Massage  in 
der  Gynakologie,  Vienna,  1887. 

8  This  is  the  name  of  a  Swedish  layman  who  is  the  inventor  and  successful  per- 
former of  most  of  the  special  massage  and  gymnastics  applied  in  gynecology. 


192  DISEASES  OF   WOMEN. 

pelvic  diseases,  but  may  be  used  to  advantage  toward  the  end  of  a 
cure  begun  on  other  lines.1 

O.  Operations  in  General. — 1 .  Time  for  operating.  If  we  have  a 
choice,  operations  should  be  avoided  in  this  climate  during  the  hot 
season.  It  is  no  small  discomfort  for  the  patient  to  lie  in  bed  for 
weeks,  when  not  even  the  nights  bring  coolness,  and  it  is  rather  trying 
for  the  operator  to  work  when  the  thermometer  is  in  the  nineties  in 
the  shade.  But  I  have  had  hospital-service  during  the  hottest  time 
of  the  year,  and  performed  both  laparotomies  and  plastic  operations 
without  the  slightest  disturbing  influence  on  perfect  success. 

In  general,  operations  should  not  be  performed  on  pregnant  women, 
on  account  of  the  danger  of  producing  miscarriage.  It  would  seem 
that  interference  with  the  rectum  is  particularly  liable  to  have  this 
effect.  As  to  the  genitals,  we  may  say  that  the  farther  the  seat  of 
operation  is  removed  from  the  uterus  the  less  is  the  danger  of  pro- 
voking abortion.  Sometimes  the  very  presence  of  pregnancy  may 
call  for  operative  interference.  Vomiting  in  pregnancy,  which  may 
lead  to  the  patient's  death,  may  be  treated  successfully  by  applying 
nitrate  of  silver  in  substance  or  in  solution  to  a  granular  os,  or  by 
stretching  the  os  and  lower  part  of  the  cervical  canal  (Copelantfs 
method}  with  the  index-finger.  Large  polypi  hanging  from  the  cervix 
may  be  the  source  of  hemorrhage  or  become  an  obstruction  during 
labor.  It  may,  therefore,  be  wise  to  remove  them  with  the  galvano- 
caustic  wire.  Ovarian  cysts  should  be  removed  if  discovered  early. 
If  the  patient  is  far  gone  or  in  labor,  tapping  may  be  preferable.  If 
a  cancer  of  the  cervix  can  be  removed,  it  is  better  to  do  so  even  with 
the  risk  of  causing  abortion,  as  the  cancer,  as  a  rule,  grows  rapidly 
during  pregnancy,  and  may  cause  an  obstruction  during  labor  that 
may  cost  the  life  of  both  mother  and  child.2 

As  a  rule,  we  avoid  operations  during  or  near  menstruation,  on 
account  of  the  great  congestion  of  the  pelvic  organs.  Most  operators 
prefer  to  operate  eight  or  ten  days  after  menstruation  has  ceased,  but 
since  we  have  seen  (p.  118)  that  the  menstrual  process  is  finished  even 
in  the  uterus  itself  eight  or  nine  days  after  the  beginning  of  the  flow, 
there  is  no  occasion  to  wait  more  than  four  or  five  days  after  it  has 
stopped.  As  the  removal  of  the  ovaries,  or  probably  rather  the  tying 
of  the  pedicle,  very  commonly  brings  on  a  menstrual  flow,  even  if  the 
patient  has  just  gone  through  her  menstrual  period  (p.  119),  it  may 
be  preferable  in  anemic  patients,  in  order  to  avoid  this  extra  loss  of 
blood,  to  operate  immediately  before  or  during  menstruation.  H.  P. 

1  The  value  of  gymnastics  as  preventive  of  and  cure  for  pelvic  disorders  has  been 
inculcated  by  John  IT.  Kellogg,  Med.  News,  November  8,  1890,  No.  930,  p.  468. 

2  Further  information  may  be  found  in  a  paper  by  M.  D.  Mann  of  Buffalo,  N.  Y. : 
"  Surgical  Operations  on  the  Pelvic  Organs  of  Pregnant  Women,"  Trans.  Amer.  Gyn. 
Soc.,  1882,  vol.  vii.  p.  340. 


TREATMENT  IN  GENERAL.  193 

C.  Wilson  [  of  Baltimore  even  prefers,  in  regard  to  laparotomies,  to 
select  the  "  uterine  flood "  rather  than  the  "  uterine  ebb,"  during 
which  he  thinks  patients  are  more  liable  to  passive  hemorrhages,  the 
absorption  of  septic  poison,  and  the  deadly  influence  of  shock,  than 
when  the  system  is  under  the  stimulus  of  the  uterine  flood.  More- 
over, he  believes  that  the  local  bloodletting  from  the  uterine  mucous 
membrane  is  a  healthy  derivation  from  many  of  the  dangers  of  lapar- 
otomy.  Tait,2  Goodell,3  and  Thomas-Munde 4  do  not  care  whether  the 
patient  menstruates  or  not.  Operators  may,  therefore,  be  warranted 
in  not  paying  much  attention  to  the  time  of  menstruation  in  regard 
to  the  performance  of  laparotomies,  and  sometimes  even  in  preferring 
the  approacli  or  the  presence  of  the  flow.  If  the  patient  menstru- 
ates, her  vagina,  after  having  been  disinfected,  should  be  filled  with  a 
tampon  of  iodoform  gauze.  Goodell  recommends  curetting  during 
menstruation  or  metrorrhagia,  but  to  avoid  this  time  in  myomectomy 
or  hysterectomy. 

Plastic  operations  ought  always  to  be  performed  shortly  after  men- 
struation, as  the  occurrence  of  this  flow  might  be  mistaken  for  hem- 
orrhage or  interfere  with  proper  after-treatment. 

Lactation  need  not  interfere  with  operations.  It  is  only  necessary 
to  discontinue  nursing  for  twenty-four  hours,  on  account  of  the  effect 
of  the  anesthetic  on  the  child,  and  press  or  pump  out  the  milk  of  the 
breasts. 

The  time  of  the  day  most  suitable  for  serious  operations  is  the 
morning,  when  the  operator  may  be  sure  not  to  have  come  near  any 
case  from  which  pathogenic  germs  might  be  brought  to  the  patient, 
and  his  own  nerves  are  refreshed  by  rest  and  sleep.  But  other  con- 
siderations often  prevail,  and  many  operate  in  the  afternoon.  Day- 
time should  always  be  preferred,  as  no  artificial  light  but  the  elec- 
tric can  replace  a  good  daylight.  If  it  is  necessary  to  operate  at  night, 
care  should  be  taken  to  obtain  as  perfect  an  illumination  as  possible. 

2.  Preparation  for  Operations. — The  more  thought  the  operator 
and  his  assistants  bestow  beforehand  on  every  detail  of  a  contemplated 
operation,  the  more  smoothly  it  will  come  off,  and,  other  things  being 
equal,  the  better  the  result  will  be. 

Room. — If  we  have  the  choice,  we  should  select  a  large  room  with 
a  good  light  for  operating,  and,  if  possible,  this  should  be  another 
room  than  the  one  in  which  the  patient  shall  lie  after  the  operation, 
but  contiguous  with  it.  The  best  room  should  be  reserved  for  the 
after-treatment.  According  to  the  season  this  should  either  be  cool 
or  have  a  southern  exposure.  For  an  important  operation,  especially 

1  Amer.  Gyn.  Trans.,  1889,  vol.  xiv.  p.  45. 

2  Tait,  Diseases  of  Women,  p.  212. 

3  Wm.  Goodell,  Med.  News,  Nov.  29,  1890,  p.  560. 

4  Thomas,  Diseases  of  Women,  6th  ed.,  p.  718. 

13 


194 


DISEASES  OF  WOMEN. 


a  laparotomy,  all  superfluous  furniture  should  be  removed,  the  carpet 
should  be  taken  up,  the  bedding  aired,  the  floor  and,  if  they  are  oil- 
painted,  also  the  walls  should  be  scrubbed,  not  only  with  soap  and 
water,  but  thereafter  with  a  solution  of  bichloride  of  mercury 
(1 : 1000).  No  curtains  should  be  allowed  round  the  bedstead. 
Every  object  should  be  carefully  dusted.  The  room  should  be  pleas- 
antly warm,  about  70°  F.,  or,  if  the  abdominal  cavity  is  to  be  opened, 
even  a  little  more  than  that. 

The  bed  should  have  a  horse-hair  mattress  and  blankets.  If  possi- 
ble, it  is  a  great  advantage  to  have  two  beds.  With  proper  precau- 
tions even  a  very  sick  patient  may  be  moved  from  one  bed  to  another, 
and  it  contributes  much  to  her  comfort. 

Table. — A  strong  narrow  table  should  be  placed  with  one  end  in 
front  of  a  window.  A  common  kitchen  table  four  feet  long  and  two 
wide  is  very  convenient.  It  should  be  covered  with  a  folded  blanket 
or  quilt,  a  muslin  sheet,  and  a  rubber  sheet  or  oil-cloth.  The  latter 
should  be  pinned  together,  so  as  to  form  a  funnel  leading  at  the  lower 
end  of  the  table,  down  into  a  slop-pail.  Instead  of  the  latter  arrange- 

FIG.  167. 


Inflatable  Surgical  Rubber  Cushions.1 

ment  inflatable  rubber  cushions  (Fig.  167)  may  be  used  to  advantage. 
A  towel  or  sheet  may  be  rolled  so  as  to  form  a  hard  cylinder,  which 
is  bent  so  as  to  form  part  of  a  circle  or  the  three  sides  of  a  square, 
and  in  the  latter  case  tied  with  strings  at  the  corners.  This  frame  is 
covered  with  a  rubber  sheet.  The  first  part  of  this  arrangement  may 
be  improvised,  and  the  latter  is  easily  carried  in  a  satchel.  A  pillow 
is  placed  at  the  head  of  the  table,  and  this  end  is  slightly  raised 

1  Howard  Kelly,  Amer.  Jour.  Obst.,  1887,  vol.  xx.  p.  1030,  but  H.  O!  Marcy  of 
Boston  claims  many  years'  priority  ( Trans.  Amer.  Association  of  Obstetricians  and 
Gynecologists,  1893,  reprint,  p.  13, 


TREATMENT  IN  GENERAL.  195 

so  that  fluids  may  gravitate  clown  into  the  pail.  For  laparotomy  it 
is  better  to  have  the  table  level  with  drainage  to  the  side  where  the 
operator  stands. 

In  hospitals  tables  are  preferably  used  that  can  be  thoroughly  dis- 
infected. Good  tables  for  this  purpose,  and  with  facility  for  Tren- 
delenburg's  position  (p.  138),  have  been  constructed  by  Cleveland, 
Edebohls,  Foerster,  and  Boldt. 

Leopold  uses  for  Trendelenburg's  position  an  apparatus  that  has 
the  advantage  of  being  inexpensive  and  so  simple  that  any  carpenter 
can  make  it.  It  consists  of  a  frame  50  inches  long  and  20  inches 
wide,  with  a  hinged  flap  that  can  be  raised  up.  The  shorter,  lower 
part  of  the  flap,  upon  which  the  legs  rest,  can  be  bent  downward,  so 
as  to  form  a  right  angle  with  the  upper  part,  upon  which  lie  the 
thighs  and  the  pelvis,  and  which  is  a  yard  long.  By  means  of  a 
support  the  flap  can  be  raised  as  much  as  20  inches  above  the  frame, 
so  that  the  support  forms  an  angle  of  about  30°  with  the  upper  part 
of  the  flap.  The  frame  is  fastened  with  iron  clamps  to  a  table  (see 
Fig.  112,  p.  139). 

McNaughton l  has  had  made  of  galvanized  iron  a  portable  attach- 
ment that  also  can  be  used  on  common  kitchen  tables.  In  hospitals 
two  long  wooden  foot-stools,  about  six  inches  high,  should  be  in  readi- 
ness to  be  used  when  the  patient  is  brought  into  Trendelenburg's 
position. 

Most  tables  are  of  a  convenient  height  for  the  operator  to  stand  at, 
but  not  only  are  perineal  and  vaginal  operations  performed  sitting, 
but  some  prefer  also  to  perform  laparotomies  in  the  sitting  posture. 
Then  the  table  should  be  rather  low,  and  the  operator  seated  on  a 
high  chair  between  the  legs  of  the  patient. 

Assistants. — For  most  operations  three,  four,  or  even  five  assistants 
are  needed,  and  each  of  them  should  have  his  part  distinctly  allotted 
and  explained  to  him  beforehand.  One  should  exclusively  be  charged 
with  the  anesthesia,  and  as  the  patient's  life  in  most  cases  depends 
much  more  on  him  than  on  the  operator,  this  function  should  be  con- 
fided to  the  most  experienced  man  available.  In  operations  with  the 
patient  in  the  lithotomy  position  one  assistant  should  hold  either  knee 
under  his  axilla,  thus  keeping  both  hands  free  for  sponging,  holding 
speculum  or  tenaculurn,  or  for  such  other  assistance  as  may  be  needed. 
In  laparotomies  one  stands  opposite  the  operator  and  the  other  at  his 
left.  A  fourth  assistant  may  be  used  to  hand  instruments,  which 
saves  time  and  allows  the  operator  to  keep  his  eyes  uninterruptedly 
on  the  field  of  operation ;  but,  in  order  to  limit  the  possible  sources 
of  infection  as  much  as  possible,  some  operators  prefer  to  place  their 
instruments  within  reach  and  dispense  with  this  assistant.  As  a 

1  McNaughton's  attachment  is  sold  by  H.  A.  Kavsan  in  Brooklyn,  N.  Y..  for 
$12.00. 


196  DISEASES  OF  WOMEN. 

rule,  the  assistance  of  a  nurse  is  required  to  hand  and  clean  sponges, 
and  attend  to  fluids,  basins,  pitchers,  syringes,  dressing-material,  etc. 

Spectato?'s. — There  can  hardly  be  any  doubt  that  the  fewer  persons 
are  present  in  the  operating-room,  the  better,  other  things  being  equal, 
are  the  chances  of  the  patient.  Particularly  in  laparotomies  the 
presence  of  persons  coining  from-  a  case  of  erysipelas,  scarlet  fever, 
diphtheria,  typhoid  fever,  or  other  zymotic  disease  constitutes  an 
element  of  danger.  On  the  other  hand,  nobody  can  learn  to  operate 
by  reading  descriptions  of  operations.  The  accumulated  experience 
of  mankind  in  this  line  can  only  be  acquired  by  seeing  others  at 
work.  And  it  is,  therefore,  in  the  interest  of  humanity  in  general 
that  operators  admit  students  and  fellow-practitioners  to  witness 
their  operations.  To  what  extent  and  with  what  restrictions  this 
should  be  done  depends  on  many  circumstances  which  cannot  be 
considered  here.  Fortunately,  experience  has  shown  that  when  those 
who  come  in  contact  with  the  field  of  operation  follow  all  the  rules 
of  antiseptic  surgery  the  mere  presence  of  other  persons  in  the  room 
has  little  or  nothing  to  do  with  the  result  of  the  operation. 

Patient. — The  patient's  urine  should  be  examined  with  special  ref- 
erence to  the  presence  of  albumin  in  the  same,  as  it  may  be  deemed 
necessary  to  postpone  the  operation  or  desist  from  it  altogether  if  the 
kidneys  are  in  a  bad  condition,  or  at  least  to  prefer  chloroform  to 
ether  as  an  anesthetic,  the  latter  having  proved  particularly  dangerous 
in  patients  with  inflamed  kidneys,1  or  to  use  opium  or  cocaine,  or 
operate  without  an  anesthetic.  If  there  is  albumin  in  the  urine,  it 
should  also  be  examined  microscopically  for  casts.  If  there  is  an  ex- 
cess of  pigment  and  salts  in  the  urine,  it  is  well  to  prepare  the  patient 
for  an  important  operation  by  the  use  of  Vichy  or  lithia  water.  If 
the  urine  contains  sugar,  the  patient  would  not  be  a  fit  subject  for  any 
plastic  operation  until  she  had  been  properly  treated  for  glycosuria. 
The  presence  of  pus  or  many  epithelial  cells  may  likewise  call  for 
special  preparatory  treatment  before  an  operation  is  undertaken. 

The  heart  and  the  lungs  should  also  be  examined.  If  the  heart  is 
diseased,  chloroform  is  particularly  dangerous.  Advanced  phthisis  is 
a  counter-indication  for  nearly  all  operations ;  in  lighter  pulmonary 
affections  ether  should  be  avoided. 

On  the  day  preceding  that  of  the  operation  the  patient  should  have 
a  warm  bath  and  be  scrubbed  with  soap  all  over,  in  order  to  have  the 
skin  in  as  good  a  condition  as  possible.  To  move  her  bowels  she  should 
toward  evening  take  a  heaping  teaspoonful  of  compound  liquorice 
powder  or  another  suitable  aperient,  and  after  that  she  should  receive 
no  other  food  than  a  little  coifee  or  beef  tea. 

Six  hours  before  the  operation  she  should  be  given  an  enenia  of  a 
quart  of  soap-suds. 

1  T.  A.  Emmet,  1.  c.,  p.  745. 


TREATMENT  IN  GENERAL. 


197 


Twenty  minutes  before  anesthesia  is  begun  I  give  a  hypodermic 
injection  of  ^  of  a  grain  of  morphine  and  ^  of  a  grain  of  sulphate 
of  atropine,  the  first  of  which  has  the  effect  that  less  of  the  anesthetic 
is  needed,  and  the  second,  that  of  strengthening  the  heart. 

Immediately  before  the  operation  begins,  the  bladder  should  be 
emptied  with  the  catheter,  even  if  the  patient  says  she  can  urinate 
herself. 

The  patient  should  be  in  night-dress,  and  the  feet,  legs,  and  thighs 
covered  with  leggings  made  of  a  woollen  or  other  warm  stuff.  In  pri- 
vate practice  stockings  are  sufficient.  Besides,  she  should  be  covered 
with  a  sheet  and  towels  in  such  a  way  as  never  to  expose  more  of  her 
body  than  needed  to  give  access  to  the  field  of  operation. 

The  field  of  operation  should  be  smeared  with  potassa  soap,  shaved, 
and  washed  with  alcohol,  if  it  is  on  the  skin,  and  bichloride  of  mer- 
cury (1 :  2000).  For  laparotomies  the  field  is  surrounded  with  four 
sterilized  towels,  pinned  together  and  to  the  clothes,  and  the  vagina  is 
carefully  disinfected  by  swabbing  with  tinctura  saponis  viridis,  fol- 
lowed by  corrosive-sublimate  solution.  Even  for  laparotomies  the 
genitals  should  be  shaved  and  disinfected.  For  operations  on  the 


FIG.  168 


Clover's  Crutch. 


external  genitals  the  buttocks  are  covered  with  a  large  piece  of  steril- 
ized gauze  in  which  a  hole  is  cut  in  front  of  the  vulva. 

For  perineal  and  vaginal  operations  the  knees  are  lifted  more  or 
less  up,  and  kept  separate  by  means  of  Clover's  o'utch  (Fig.  168),  an 


198  DISEASES  OF  WOMEN. 

expensive  apparatus  which,  however,  may  easily  be  replaced  at  small 
cost  by  placing  a  two-feet-long  broomstick  in  the  popliteal  spaces, 
tying  it  with  some  figure-of-eight  turns  to  each  knee  with  a  roller- 
bandage,  and  leading  part  of  the  bandage  up  behind  the  neck  of  the 
patient. 

An  inexpensive  leg-holder  is  that  of  Robb  (Fig.  169).     It  is  easily 

FIG.  169. 


Robb's  Leg-holder. 

rolled  up,  and  takes  up  little  room  in  the  satchel.  It  surrounds  the 
lower  part  of  the  thigh,  passes  under  the  right  shoulder  and  above 
the  left,  which  is  protected  against  pressure  by  a  thick  pad  of  cotton 
batting  being  placed  between  it  and  the  leg-holder.  I  have,  however, 
seen  several  cases  of  semi-paralysis,  numbness,  and  pain  in  the  arm 
or  leg  follow  its  use.  But  similar  effects  are  observed  with  other 
apparatus,  and  seem  to  be  due  to  the  anesthetic  and  not  to  pressure. 
Good  operating- tables  have  special  uprights  with  stirrups  to  which 
the  feet  are  attached  in  an  elevated  position. 

Vessels  and  Towels. — Two  instrument  trays  of  hard  rubber,  enam- 
elled iron,  china,  or  glass  should  be  kept  ready,  likewise  4  plates  for 
ligatures,  sutures,  iodoform  gauze,  and  gutta-percha  tissue ;  4  basins ; 
4  pitchers,  with  hot  water,  cold  water,  carbolized  water  (5  per  cent.), 
solution  of  bichloride  of  mercury  (1 : 1000);  2  fountain  syringes  or 
douche-cans,  with  a  straight  glass  nozzle  6  inches' long,  and  a  hard- 
rubber  nozzle  with  a  stopcock  easily  opened  and  closed  with  the  thumb 
(Fig.  170). 

At  least  a  dozen  towels  will  be  needed. 

Disinfection,  Asepsis,  and  Antisepsis. — In  hospitals  and  so  far  as 
possible  in  private  practice  operations  should  be  performed  according 


TREATMENT  IS  GENERAL.  199 

to  the  rules  of  aseptic  surgery,  but  in  private  practice  this  is  some- 
times not  feasible,  and  then  a  high  degree  of  safety  is  yet  obtainable 
by  strict  adherence  to  antiseptic  measures.  Common  for  both  sys- 
tems is  the  disinfection  of  the  room,  the  field  of  operation,  the  ope- 
rator and  his  assistants.  In  aseptic  surgery  the  disinfectant  agent 

FIG.  170. 


Nozzle  with  Stopcock. 

relied  on  is  heat  in  the  shape  of  boiling  water  or  moving  steam  ;  in 
its  antiseptic  forerunner  the  same  is  aimed  at  by  means  of  chemicals 
that  possess  germicidal  power.  In  the  instrument-stores  are  found 
more  or  less  costly  apparatus  for  rendering  instruments,  gauze  pads, 
towels,  coats,  etc.,  aseptic,  but  the  same  may  be  obtained  at  small  expense 
by  using  utensils  that  are  on  the  market  for  other  purposes.  Thus, 
an  agate-ware  asparagus-boiler  is  an  excellent  instrument-boiler, 
and  a  large-sized  Arnold  milk  sterilizer  can  be  used  for  gauze, 
towels,  etc. 

Instruments  are  boiled  for  five  minutes  in  a  solution  of  bicarbonate 
of  sodium — a  tablespoonful  to  the  quart.  Even  cutting  and  pricking 
instruments  are  disinfected  in  this  way,  but  should  be  wrapped  up  in 
gauze  so  as  not  to  be  mechanically  injured.  Gauze,  towels,  and  other 
material  are  disinfected  by  having  a  current  of  steam  circulate  through 
them  for  an  hour. 

We  have  already  referred  to  the  disinfection  of  the  room  and  the 
field  of  operation.  The  operator  and  his  assistants  take  off  their 
coats,  turn  up  their  sleeves  to  the  elbow,  scrub  their  hands  and  fore- 
arms with  potassa  soap  and  hot  water,  using  a  rather  stiff  nail-brush, 
wipe  their  hands,  remove  all  dirt  from  under  the  nails  with  a  steel 
nail-scraper,  and  scrub  the  hands  in  a  solution  of  bichloride  of  mer- 
cury (1  :  2000)  for  at  least  three  minutes,  after  which  they  should 
not  wipe  the  hands.  To  combine  the  use  of  soap  and  corrosive  sub- 
limate in  disinfecting  the  hands  is  wrong,  as  the  soap  deprives  the 
drug  of  some  of  its  power.  On  the  other  hand,  disinfection  is  much 
improved  by  immersing  the  hands  in  alcohol  or  washing  them  with 
the  same  for  five  minutes  before  rinsing  them  in  bichloride  solution. 
It  is  convenient  to  put  on  a  rubber  apron  covering  the  whole  front 
of  the  body  from  the  neck  down  to  a  little  above  the  feet,  and  to  pin 
to  this  a  towel  wrung  out  of  carbolized  water,  or  sterilized,  or,  still 
better,  to  put  on  a  sterilized  coat  and  cap. 

For  dressing,  the  antiseptic  materials,  such  as  iodoform  gauze  or 
corrosive-sublimate  gauze,  sold  by  druggists  and  instrument-makers, 


200 


DISEASES  OF  WOMEN. 


may  be  used,  but  much  of  so-called  aseptic  ligature  and  suture  mate- 
rial and  sponges  found  on  the  market  is  unreliable.1 

Entirely  reliable  sterile  sutures  are  prepared  by  Geo.  St.  John 
Leavens,  72  Bible  House,  New  York.  They  come  in  sealed  glass 
tubes,  and  are  sterilized  by  boiling  in  absolute  alcohol  at  250°  Fahr. 


FIG.  171. 
A 


Leavens'  Suture-tubes :  A,  sterilized  at  250°  F.  after  sealing ;  B,  opened  at  operation. 

for  forty-five  minutes  after  sealing.  At  the  time  of  operating  the 
tubes  are  broken  (Fig.  171). 

Sponges. — The  raw  sponges  are  beaten  in  order  to  soften  them  and 
remove  sand,  and  then  immersed  in  acidulated  water  (acid,  hydro- 
chlor.  %j  to  each  quart  of  water)  in  order  to  dissolve  the  calcareous 
matter.  Part  of  this  trouble  may  be  avoided  by  buying  the  sponges 
already  prepared ;  but  even  then  they  have  to  be  treated  with  the 
acidulated  water,  and  wrung  many  times  out  of  water  until  all  sand 
has  been  removed. 

When  sponges  have  been  used  in  an  operation,  they  are  cleaned  in 
the  following  way :  They  are  first  washed  with  soap  and  water  until 
the  water  remains  clean ;  then  they  are  left  for  an  hour  in  a  solution 
of  potassa  (liquor,  potassse  3j  to  each  quart  of  water)  which  draws 
out  all  the  blood.  If  the  sponges  have  been  unusually  soaked  in 
blood,  it  may  become  necessary  to  change  this  solution.  Then  they 
are  again  wrung  out  of  plain  water  till  it  stays  clear.  After  that 
they  are  left  for  an  hour  in  a  solution  of  bichloride  of  mercury 
(1  : 1000),  wrung  out,  dried  in  the  sun  or  in  front  of  a  fire,  and  kept 
in  a  muslin  bag.  By  keeping  them  in  this  dry  way  they  do  not  be- 
come rotten  so  soon  as  when  kept  in  an  antiseptic  fluid.  Before 
using  them  the  next  time  they  are  left  for  five  or  ten  minutes  in  a 

1  Aseptic  material  may  be  prepared  in  many  ways ;  I  describe  only  the  one  I 
follow  myself. 


TREATMENT  IN  GENERAL.  201 

similar  solution  of  bichloride,  after  having  soaked  them  well  by 
pressing  all  the  air  out  of  them,  wrung  out,  and  kept  in  carbolized 
water  (2  or  2J  per  cent.)  or  plain  boiled  water  during  the  opera- 
tion. 

Three  sizes  of  sponges  are  needed:  small  round  about  1£  inches 
in  diameter;  large  round,  about  3  inches  in  diameter ;' and  large  flat 
sponges,  J  inch  thick. 

Most  operators,  in  order  to  avoid  infection  from  sponges  or  the 
trouble  of  disinfecting  them,  have  discarded  them  altogether,  and  use, 
instead  of  round  sponges,  small  pads  of  sterilized  gauze  or  round  balls 
of  absorbent  cotton  wound  with  gauze,  and  instead  of  the  flat  sponges 
pads  of  several  layers  of  gauze,  about  8  by  6  inches.  Such  gauze 
sponges  are  sterilized  with  heat  in  Arnold's  milk-sterilizer  or  some 
other  apparatus  through  which  steam  circulates. 

Silk. — Twisted  or  braided  silk  is  used :  the  latter  is  stronger. 
Four  thicknesses  are  needed  :  Nos.  1,  2,  5,  and  12  of  the  braided. 

In  order  to  render  it  aseptic  it  is  boiled  in  a  small  china  casserole 
over  an  alcohol  lamp  for  half  an  hour,  and  soaked  in  a  solution  of 
bichloride  of  mercury  (1  :  1000)  for  an  hour,  wound  on  glass  spools, 
several  of  which  may  be  suspended  on  one  glass  stand  and  kept  in 
alcohol  in  a  well-corked  glass  with  a  heavy  bottom.  Such  glasses 
can  be  obtained  from  the  instrument-makers.  The  different  ends 
may  be  run  through  holes  in  the  cork  or  rubber  stopper  covering  the 
glass,  and  thus  the  silk  is  unwound  without  opening  the  bottle.  If 
there  is  a  hitch,  great  care  should  be  taken  only  to  use  a  perfectly 
aseptic  pair  of  forceps  to  get  hold  of  the  silk  or  the  spools.  New 
alcohol  must  be  constantly  poured  into  the  bottle  to  keep  it  full,  and 

FIG.  172. 


Schimmelbusch's  Metal  Box  for  Sterilizing  Silk  and  Keeping  it  Sterile:  A,  box  opened  in 
order  to  expose  the  silk  to  the  circulating  steam  of  the  sterilizer;  B,  partly  closed  as 
when  in  use. 

if  not  used  often  the  silk  should  from  time  to  time  be  boiled  again, 
and  the  alcohol  renewed  altogether.    Where  a  steam  sterilizer  is  avail- 

"^CO  LLUG :: 
R-i  V  £  c  C 


202  DISEASES  OF  WOMEN. 

able,  the  silk  is  sterilized  immediately  before  each  operation  by  being 
placed  in  the  sterilizer.  Schimmelbusch  of  Berlin  has  constructed  a 
practical  metal  box  for  this  purpose  (Fig.  172). 

I  have  had  a  ligature-box  made  (Fig.  173)  which  is  a  modification 
of  that  described  by  Greig  Smith.1  It  consists  of  a  solid  hard  rubber- 
box,  to  which  is  screwed  a  cap.  A  -leather  washer  is  placed  at  the 
bottom  of  the  screw.  Into  this  case  fits  a  leaden  disk  which  is  heavy 
enough  to  remain  stationaiy  while  the  silk  is  being  drawn  out,  and 
on  this  disk,  supported  by  upright  rods  of  German  silver,  are  placed 
four  metal  reels  of  the  same  material.  A  glass  plate  perforated  in 
four  places  for  the  threads  is  screwed  to  the  top  of  a  central  bar. 
This  whole  inner  part  may  be  boiled  in  water  or  any  solution  the  ope- 
rator may  prefer,  and  the  box  is  immersed  in  a  solution  of  corrosive 
sublimate ;  and  when  once  all  is  aseptic,  it  is  kept  so  by  keeping  the 
box  filled  with  alcohol.  By  winding  the  reels  with  finest  black  iron- 
dyed  silk,  and  braided  No.  2,  4  or  5,  and  12,  the  operator  is  prepared 

FIG.  173. 


Greig  Smith's  Ligature-box  (modified). 


for  everything  that  needs  tying,  from  a  wound  in  the  intestine  to  the 
thickest  pedicle  of  a  tumor. 

Catgut,  so  called,  is  in  reality  sheep's  gut.  It  is  so  hard  to  render 
it  aseptic,  and  keep  it  so,  that  some  have  given  it  up  altogether,  but 
its  absorbability  makes  it  very  valuable  for  ligatures  and  buried  su- 
tures. A  simple  and  excellent  way  of  preparing  it  is  to  boil  it  in  so- 
called  absolute  alcohol  (97  per  cent.,  or  even  in  the  common  95  per 
cent.)  for  an  hour  and  keep  it  in  the  same  alcohol.2 

1  Greig  Smith,  Abdominal  Surgery,  2d  ed.,  Philadelphia,  1888,  p.  65. 

1  George  E.  Fowler  of  Brooklyn,  N.  Y.  Med.  Record,  1890,  vol.  xxxviii.  p.  178. 


U 


TREATMENT  IN  GENERAL. 


203 


This  method  has  been  made  easy,  inexpensive,  and  safe  by  means 
of  Dowd's  condenser,  represented  in  Fig.  174.1  The  catgut  is  wound 
on  glass  reels  enclosed  in  small  glaas  jars,  which  are  immersed  in 
alcohol  in  a  larger  jar  placed  in  a  water-bath  on  a  gas-stove.  From 
the  top  of  the  large  jar  the  vapor  of  the  boiling  alcohol  rises  into  a 
coil  of  tin,  in  which  it  is  condensed  by  having  cold  water  flowing 
through  the  surrounding  copper  cylinder,  and  from  which  it  drops 
back  into  the  jar  below.  For  hospital  use  the  catgut  may  simply  be 
boiled  in  a  covered  glass  with  alcohol  standing  iu  a  casserole  with 
water  during  the  preparation  for  the  operation. 

For  the  intestines  No.  0  is  required  ;  for  closing  the  peritoneum  in 
laparotomies  I  use  No.  1 ;  for  the  perineum  a  medium  size  is  used  ; 


FIG.  174. 


Dowd's  Apparatus  for  the  Sterilization  of  Catgut. 

and  for  the  pedicles  of  tumors  a  very  thick  one.  Different  manufac- 
turers use  different  numbers,  so  that  I  cannot  designate  the  thickness 
in  that  way. 

1  Charles  N.  Dowd  of  New  York,  Med.  Record,  Dec.  3,  1892. 


204  DISEASES  OF  WOMEN. 

Catgut  has  the  advantage  over  silk  that  it  is  soon  dissolved  and 
absorbed,  which  recommends  it  for  ligatures  in  wounds  or  cavities 
from  which  it  cannot  be  removed,  and  for  sutures  in  so  far  as  its 
removal  becomes  unnecessary.  The  thick  grades  are  so  strong  that 
they  never  break  in  being  tightened.  It  has  therefore  been  recom- 
mended as  exclusive  material  for  both  ligatures  and  sutures,  while 
others  as  exclusively  use  silk  for  all  purposes.  On  the  other  hand, 
catgut  is  more  difficult  to  tie,  becomes  easily  untied,  so  that  triple 
knots  are  necessary  where  there  is  any  strain  on  it,  and,  as  before 
stated,  it  is  more  difficult  to  render  and  keep  aseptic.  Its  great  dis- 
solvability  proves  even  sometimes  a  fault  instead  of  a  virtue ;  which, 
however,  can  be  remedied  by  preparing  it  with  chromic  acid  in  the 
following  way :  Soak  the  catgut  in  oil  of  juniper  for  twenty-four  hours ; 
wash  off  the  juniper  oil  by  soaking  the  catgut  in  ether  a  few  minutes; 
soak  the  catgut  in  a  watery  solution  of  bichromate  of  potassium — grs. 
2£  to  the  ounce — for  from  fifteen  to  thirty  minutes,  according  to  the 
length  of  time  one  wants  it  to  remain  unabsorbed  ;  wash  the  catgut  in 
alcohol ;  place  the  catgut  in  bottles ;  fill  up  with  alcohol,  and  boil  for 
five  minutes  in  a  water-bath.  If  the  catgut  is  to  be  wound  on  reels, 
this  should  be  done  after  it  has  been  taken  from  the  bichromate-of- 
potassium  solution  and  before  it  has  been  washed  in  alcohol.1 

Silkwwm  gut  is  sold  "prepared"  in  a  long  bundle  tied  at  both  ends. 
It  may  be  disinfected  by  boiling  it  in  water.  As  many  single  threads 
as  are  likely  to  be  used  are  cut  off  before  the  operation,  washed  in  a 
solution  of  bichloride  (1  : 1000),  and  kept  in  carbolized  water  (2  per 
cent.)  during  it,  just  like  sponges.  It  is,  of  all  materials,  the  best  for 
operations  on  the  perineum.  It  does  not  absorb  fluid  like  silk,  does 
not  become  corroded  like  catgut,  and  does  not  hurt  in  removal  like 
silver  wire. 

Horsehair  is  an  excellent  material  for  many  purposes,  especially  for 
enterorrhaphy  according  to  Maunsell's  method.2  The  hair  should  be 
taken  from  a  male  animal.  The  longest  and  strongest  hairs  without 
a  flaw  should  be  selected,  tied  at  one  end,  brushed  up  with  soap  and 
water.  Next  they  should  be  immersed  in  bichloride-of-mercury  solu- 
tion (1  : 4000)  for  two  or  three  hours.  After  that  they,  are  shaken  out 
and  placed  in  a  large  glass-stoppered  bottle.  Before  being  used  they 
should  be  immersed  in  bichloride  solution  for  several  hours,  in  order 
to  make  them  pliable. 

Kangaroo  tendon  shares  with  catgut  the  advantage  of  being  absorb- 
able,  and  resists  for  a  longer  time  absorption,  which  makes  it  particu- 
larly valuable  for  certain  operations,  such  as  radical  hernia  operations, 
but  its  high  price  is  in  the  way  of  a  general  use  of  it. 

Silver  Wire. — Silver  wire,  or  its  much  cheaper  substitute  silver- 

1  Private  communication  from  Dr.  A.  Palmer  Dudley. 

2  Maunsell,  Amer.  Jour.  Med.  Sci.,  March,  1892. 


TREATMENT  IN  GENERAL.  205 

plated  copper  wire,  is  made  aseptic  by  immersion  in  5  per  cent,  car- 
bolized  water  or  by  drawing  it  through  the  flame  of  an  alcohol  lamp, 
and  is  kept  during  the  operation  in  carbolized  water  or  alcohol.  The 
thicknesses  commonly  used  are  No.  26  for  the  perineum,  No.  27  for 
the  cervix,  and  No.  28  for  the  vagina.  But  it  is  used  much  less  now 
than  some  years  ago. 

lodoform  is  not,  in  itself,  an  antiseptic,  but  it  seems  that  it  is  de- 
composed by  the  very  appearance  of  pus-cocci  and  the  formation  of 
ptomaines  in  such  a  way  as  to  become  a  germicide.  However  this 
may  be,  experience  has  shown  that  it  is  a  most  valuable  preventive 
of  suppuration  and  sepsis.  Its  disagreeable  odor  may  be  covered  by 
adding  1  part  of  thymol  to  5  parts  of  iodoform.1  A  chemical  com- 
bination of  the  two  has  been  introduced  under  the  name  of  aristol. 
Coumarin,  the  odoriferous  principle  in  Tonka  beans  (1  part  to  5), 
and  ground  coffee  are  also  recommended  for  the  purpose.  lodoform 
gauze  may  be  disinfected  by  placing  it  in  a  closed  glass  jar  in  the 
sterilizer  for  half  an  hour.  Its  color  changes  partially  to  blue  by  a 
combination  of  the  iodine  and  the  starch  contained  in  the  gauze,  but 
in  contact  with  tissue  iodoform  is  reproduced. 

Antiseptic  Fluids. — Bichloride  of  mercury  is  a  powerful  antiseptic, 
but  so  poisonous  that  it  has  to  be  used  with  great  circumspection. 
Experiments  have  shown  how  fatal  the  effect  of  a  solution  of  bichlo- 
ride of  mercury  is  when  it  is  kept  in  contact  with  a  wound  leading 
into  the  subcutaneous  connective  tissue,  and  the  same  applies,  of 
course,  to  the  submucous.  Even  the  intact  mucous  membrane  of  the 
vagina  absorbs  it.2  I  have,  therefore,  nearly  entirely  discarded  it  for 
intra-uterine  and  vaginal  injection  and  irrigation  of  wounds  or  the 
peritoneal  cavity.  I  use  it  almost  exclusively  for  washing  the  skin 
and  the  vagina,  and  for  the  hands  of  the  doctors  and  nurses.  It  is 
convenient  to  have  a  solution  of  1  :  1000,  which  may  be  diluted  by 
adding  hot  water. 

Carbolic  acid  is  used  for  instruments  and  sponges.  It  is  best  to 
have  a  5  per  cent,  solution,  and  add  hot  water  so  as  to  get  a  2J  or  2 
per  cent,  solution. 

Creolin  forms  no  solution,  but  an  emulsion,  with  water.  This 
emulsion  should  be  prepared  by  pouring  the  creolin  into  cold  water, 
stirring  it,  and  adding  as  much  hot  water.  The  strength  that  answers 
best  in  most  cases  is  a  1  per  cent,  emulsion  (2  tablespoonfuls  to  3 
quarts  of  water),  but  both  J  per  cent,  and  2  per  cent,  solutions  are  used. 
The  emulsion  looks  like  milk  with  a  little  coffee.  It  has  the  fault  of 
being  opaque  and  of  producing  a  smarting  sensation  in  the  vagina  of 
some  patients.  It  is  not  so  powerful  an  antiseptic  as  bichloride  of 

1  Med.  World,  1886,  p.  89. 

2  Details  may  be  found  in  my  article  on  "Corrosive  Sublimate  and  Creolin," 
Amer.  Jour.  Med.  Sci.,  1889,  vol.  xcviii. 


206  DISEASES  OF  WOMEN. 

mercury,  but,  compared  with  carbolic  acid,  it  has  the  advantage  of 
being  an  excellent  hemostatic,  of  being  almost  innocuous,  of  making 
the  tissues  slippery,  of  having  a  rather  pleasant  odor,  and  of  not  affect- 
ing the  operator's  skin  and  nerves.  I  use  it  after  curetting,  especially 
for  cancer,  where  its  hemostatic  powers  prove  of  great  value. 

Lysol  has  the  advantage  over  creolin  of  forming  a  nearly  clear  mix- 
ture with  water.  It  is  used  in  the  same  strength,  is  slippery,  and  has 
a  less  pungent  odor.  For  injection  it  has  to  a  great  extent  replaced 
the  other  disinfectants,  but  it  is  not  suitable  for  operations,  as  it  be- 
comes nearly  black  by  mixture  with  blood,  renders  tissue  and  instru- 
ments too  slippery,  and  foams. 

Hydro-naphthol  is  much  praised  by  the  few  who  use  it.  "  It  is  harm- 
less and  does  not  injure  instruments  or  operator's  hands.  The  strength 
used  is  a  saturated  solution  in  hot  water.  The  peritoneal  cavity  may 
be  repeatedly  filled  with  this  solution  with  perfect  impunity."  * 

Boro-salieylic  solution,  or  Thiersch's  solution  (R  :  Acidi  borici  12, 
Acidi  salicylici  2,  Aquae  1000),  is  a  bland  fluid  that  likewise  may  be 
used  in  the  peritoneum  or  for  irrigation  of  wounds.2 

Thymol  (1 : 1000)  is  also  a  bland  disinfectant. 

3.  Anesthesia. — The  two  chief  anesthetics  used  are  ether  and  chlo- 
roform. Ether,  as  the  safer  of  the  two,  should  be  preferred,  except 
when  the  kidneys,  the  lungs,  the  larynx,  or  trachea  are  affected  or  in 
patients  suffering  from  congestion  of  the  brain,  for  under  these  cir- 
cumstances ether  is  the  more  dangerous  of  the  two.  It  seems,  also, 
that  there  are  differences  of  susceptibility  to  the  effect  of  the  two 
drugs  in  different  persons.  I  have  had  cases  where  one  of  them, 
ether  as  well  as  chloroform,  failed  to  induce  anesthesia,  but  caused 
alarming  symptoms,  such  as  convulsions  or  arrest  of  respiration, 
while  the  other  worked  satisfactorily. 

Some  prefer  mixtures  of  ether  and  chloroform  in  different  propor- 
tions, usually  combined  with  absolute  alcohol.  A  combination  of  this 
kind  is  known  as  the  A.  C.  E.  mixture : 

I|i.  Alcohol  absoluti,  sj  ; 

Chloroformi  purificati,  gij  ; 

JEtheris  fortioris,  liij. 
M.     S. — A.  C.  E.  mixture  for  inhaling. 

Personally  I  have  been  much  pleased  with  this  mixture.3 

1  Clinton  Gushing,  Pacific  Med.  Jour.,  July,  1890,  reprint,  p.  7.  First  recom- 
mended by  Geo.  R.  Fowler  of  Brooklyn,  N.  Y.,  New  York  Med.  Jour.,  1885,  vol. 
xiii.  p.  374  et  seq.,  and  endorsed  by  R.  J.  Levis  of  Philadelphia,  ibid.,  p.  593. 

8  A  convenient  way  of  making  this  solution  is  by  dissolving  Thiersch's  tablets  in 
water,  1  tablet  to  each  quart. 

8  It  is  much  praised  by  John  C.  Reeve,  Dayton,  O.  ( Trans.  Amer.  Gynecol.  Soc., 
1891,  vol.  xvi.  p.  20) ;  and  Lawson  Tait  declares  the  combination  to  be  a' great  ad- 
vance over  either  ether  or  chloroform  used  separately  (Buffalo  Med.-Sury.  Jour., 
quoted  in  Med.  Brief,  May,  1894,  p.  630). 


TREATMENT  IN  GENERAL. 


207 


In  giving  ether  constant  watch  should  be  kept  on  the  respiration. 
As  soon  as  it  stops,  etherization  should  be  interrupted,  and  artificial 
respiration  by  Sylvester's  method  or  Richardson's  double-acting 
bellows  be  instituted.  In  giving  chloroform  special  attention  has  to 
be  directed  to  the  pulse,  for  when  breathing  stops  under  the  use  of 
that  drug  there  is  great  danger  that  the  heart  will  be  fatally  affected. 
In  case  of  collapse  during  chloroform ization,  the  best  treatment  is  the 
combination  of  artificial  respiration  with  Nelaton's  method,  which 
consists  in  suspending  the  patient  by  holding  her  knees  over  the 
shoulders  of  an  assistant  and  letting  her  head  hang  down.  I  have 
succeeded  every  time  with  this  combination. 

Another  method  that  may  answer  a  good  purpose,  even  at  a  later 
stage,  is  Koenig's  rapid  compression  of  the  heart.  The  ball  of  the 
thumb  is  pressed  against  the  wall  of  the  chest  between  the  apex  of 
the  heart  and  the  left  edge  of  the  sternum  120  times  or  oftener  in 
the  minute.  When  the  pupils  contract  and  the  patient  breathes,  a 
pause  is  made  until  the  former  dilate  again  and  the  respiration 
stops. 

If  there  has  been  considerable  loss  of  blood  and  the  heart  threatens 
to  become  paralyzed,  an  intravenous  injection  of  a  6-per-thousand 
solution  of  common  salt  (sodium  chloride)  at  the  temperature  of  the 
blood  may  yet  save  the  patient's  life. 

Ether  is  given  with  Attis's  inhaler  (Fig.  175),  a  frame  of  metal 
with  many  parallel  long  side-openings, 
through  which  a  roller  bandage  is  drawn 
and  surrounded  by  a  soft  rubber  cover. 
The  inventor  describes  its  use  in  the  fol- 
lowing words  :  "  Placing  it  over  the  face,  I 
sprinkle  on  a  few  drops  of  ether :  I  mean, 
literally,  but  a  few  drops.  In  a  few  sec- 
onds I  add  a  few  more  drops,  and  usually 
in  from  half  a  minute  to  a  minute  I  find 
that  I  can  drop  it  more  constantly.  As 
soon  as  I  notice  the  deep  inspiration  I  pour 
on  a  small  stream,  watching  carefully  lest  I 
irritate  the  larynx ;  and  as  soon  as  I  find 
the  patient  tolerant  of  its  vapor,  I  add  it  in 
larger  quantities,  and  as  rapidly  as  it  can  be 
evaporated,  and  am  usually  gratified  by  see- 
ing my  patient  pass  quietly  under  its  influ-  Aiiis's  Ether-inhaler. 
ence  in  from  three  to  ten  minutes.  A  slight 

dripping  will  suffice  to  prolong  the  effect."  The  chief  virtue  of 
Allis's  inhaler  is  the  free  access  of  air,  and  his  method  is  much  to  be 
preferred  to  the  one  usually  followed.  , 

Often  a  substitute  is  improvised  by  folding  a  newspaper  and  a 


FIG.  175. 


208  DISEASES  OF  WOMEN. 

towel  together,  so  as  to  form  a  kind  of  cap,  into  the  bottom  of  which 
is  put  a  little  absorbent  cotton.  About  a  fluidounce  of  ether  is 
poured  on  the  cotton,  and  more  added  when  it  has  evaporated. 

Other  inhalers — e.  g.  Ormsby's — admit  very  little  air,  and  make  the 
patient  all  the  time  inspire  the  same  air  she  expires,  so  that  there 
really  is  a  combination  of  etherization  and  poisoning  with  carbonic 
acid.  This  class  of  instruments  use  a  much  smaller  amount  of  ether. 
Ormsby's  has  a  metal  cone  with  a  small  sponge  at  the  top  and  an  in- 
flatable rubber  ring  at  the  brim,  which  can  be  placed  air-tight  over 
the  face.  The  ether  is  poured  on  the  sponge  through  a  small  funnel. 
Air  may  be  admitted  in  small  quantities  through  an  opening  on  the 
side  of  the  cone,  which  can  be  made  larger  or  smaller.  On  the  other 
side  of  the  sponge  is  a  rubber  bag  into  which  the  patient  expires,  and 
from  which  she  again  inspires.  This  method  is  in  my  opinion  more 
dangerous  than  that  of  Allis. 

As  often  a  considerable  amount  of  ether  is  used,  it  is  best  to  have 
a  pound  of  it  on  hand,  but  divided  into  quarter-pound  cans.  Even 
in  hospitals  it  is  better  to  have  these  .small  cans,  because  ether  under- 
goes some  change  as  soon  as  the  can  has  been  opened,  in  consequence 
of  which  it  loses  part  of  its  anesthetic  power,  and  a  larger  quantity  is 
needed  to  produce  the  same  effect. 

The  use  of  a  hypodermic  injection  of  morphine  before  giving  ether 
does  not  abridge  the  time  required  to  induce  anesthesia,  but  offers  the 
advantage  that  very  little  or  nothing  is  needed  to  keep  up  the  effect. 

The  vapor  of  ether  is  inflammable.  Great  care  must,  therefore,  be 
taken  not  to  bring  the  ether-cone  or  bottle  too  near  the  flame  or  in- 
candescent body  when  a  cautery  is  used,  or  when  the  operation  is 
performed  with  artificial  light,  or  in  a  room  with  an  open  fire.  It  is 
safe  to  have  gas-lights  a  yard  above  the  operating  table.1  My  own 
experiments  have,  indeed,  proved  that  a  compress  saturated  with  ether 
does  not  catch  fire  from  a  burning  candle  before  the  flame  is  approached 
to  the  distance  of  one  inch  from  below  or  from  the  side,  and  even 
half  an  inch  from  above.  Ether  vapor  contained  in  the  breath  is 
not  inflammable. 

Of  chloroform  it  is  well  to  have  four  ounces.  It  is  best  adminis- 
tered on  Esmarch's  mask  (Fig.  176),  which  consists  of  a  wire  skeleton 
covered  with  Canton  flannel.  It  lies  over  nose  and  mouth,  and  the 
chloroform  is  dropped  on  it  without  removing  it.  Instead  of  the 
mask  a  pocket-handkerchief  may  be  used,  but  then  the  face  should 
be  smeared  with  vaseline  in  order  to  protect  the  skin  from  irritation. 
Chloroform  should  be  given  in  the  dose  of  5  to  10  drops  poured  on 
the  mask  at  intervals  of  half  a  minute.  Death  from  chloroform 
appears  in  four  modes :  (a)  By  syncopal  apnea ;  (6)  by  epileptiform 

1  J.  K.  Corate,  "  Ether  et  Chloroforme,"  Revue  medicate  de  la  Suisse  Romande,  20 
F^vrier,  1890,  p.  87. 


TREATMENT  IN  GENERAL. 


209 


syncope ;  (c)  by  paralysis  of  the  heart  with  paralysis  of  the  muscular 
system  generally ;  (d)  by  chloroform  combined  with  surgical  shock.1 

FIG.  176. 


Esmarch's  Chloroform-Mask. 

Since  in  chloroformizatiou  there  is  so  much  danger  of  paralysis  of 
the  heart,  it  is  well  to  add  -^  grain  of  sulphate  of  atropine  to  the 
preliminary  hypodermic  injection. 

The  A.  C.  E.  mixture  is  administered  with  Allis's  inhaler,  from  20 
to  30  drops  at  a  time,  repeated  every  half  minute. 

"Whatever  anesthetic  is  used,  false  teeth  should  be  removed  before 
beginning ;  a  gag  to  separate  the  jaws,  a  long  dressing  forceps,  and 
some  gauze  or  lint  should  be  within  reach  for  the  removal  of  froth, 
which  sometimes  accumulates  in  the  throat.  The  tongue  should 
always  be  kept  forward,  which  can  be  done  by  pressing  both  rami  of 
the  lower  jaw  forward.  Special  tongue-forceps  are  found  in  the 
instrument-stores.  The  tongue  should  not  be  pinched  with  artery- 
forceps,  which  causes  bad-looking  and  painful  ulcerations. 

Particular  care  should  be  taken  when  Trendelenburg's  position  is 
used,  as  it  tends  to  produce  congestion  of  the  brain.  Some  prefer  for 
this  reason  to  use  chloroform.2  At  all  events,  the  patient  should  be 
anesthetized  in  the  horizontal  position,  not  kept  inclined  longer  than 
necessary,  and  brought  back  to  the  horizontal  position,  at  least  tem- 
porarily, if  she  becomes  cyanosed. 

Cocaine. — Although  great  operations,  such  as  ovariotomy  and  am- 
putation of  the  breast,  have  been  successfully  performed  under  the 
anesthesia  brought  on  by  hypodermic  injection  of  hydrochlorate  of 
cocaine,  so  many  cases  of  alarming  depression  following  the  use  of 
even  very  small  doses  are  on  record  that  I  think  the  use  of  this  drug 
should  be  very  limited  in  gynecological  practice.  Perhaps  it  inter- 
feres also  with  healing  by  the  first  intention.3 

It  is,  however,  in  many  cases,  a  great  advantage  to  dispense  with 
general  anesthesia,  and  it  has  been  noticed  that  the  dangerous  collapse 

1  Benjamin  Ward  Richardson,  "On  Death  by  Chloroform,"  The  Asdepiad,  1st 
quarter,  1890. 

2  Cleveland  and  Goodell,  Amer.  Jour.  06s/.,  Oct.,  1891.  vol.  xxiv.  p.  1240. 
8  H.  T.  Hanks,  Amer.  Jour.  Obst.,  1888,  vol.  xxi.  p.  316. 

14 


210  DISEASES  OF  WOMEN. 

is  less  likely  to  occur  the  farther  away  from  the  head  cocaine  is  used. 
I  have  been  well  satisfied  with  the  application  of  a  10  per  cent,  solu- 
tion before  cauterization  with  chloride  of  zinc  in  diphtheritic  inflam- 
mation of  the  genitals.  The  cervix  may  be  dilated  without  pain 
after  pledgets  soaked  in  a  5  to  20  per  cent,  solution  are  placed  for 
five  minutes  around  it,  and  in  its  cavity  if  it  is  sufficiently  wide  to 
allow  it. 

In  cases  in  which  general  anesthesia  was  deemed  to  be  too  danger- 
ous on  account  of  heart  disease,  even  the  largest  operations,  such  as 
ovariotomy  and  abdominal  hysterectomy,  have  been  performed  with 
local  anesthesia  produced  with  a  spray  of  chloric  ether,  or  ethyl  chlo- 
ride. This  substance  is,  at  a  temperature  below  50°  Fahr.,  a  fluid. 
It  is  stored  in  tubes  and  a  stream  of  the  rapidly  volatilizing  fluid  be- 
comes a  spray.  It  should  be  held  10  inches  away  from  the  part 
treated  in  order  to  avoid  excessive  and  useless  cold.  The  gas  is  very 
inflammable,  and  in  operations  the  neighborhood  of  a  flame  must  be 
avoided. 

Whatever  agent  be  used  to  produce  anesthesia,  the  most  powerful 
stimulants  should  be  kept  ready.  A  few  drops  of  nitrite  of  amyl  are 
good  where  there  are  signs  of  anemia  of  the  brain  (chloroform,  cocaine). 
Hypodermic  injections  of  several  syriugefuls  of  brandy  often  increase 
the  volume  of  a  sinking  or  indiscernible  pulse.  Still  more  powerful  is 
the  hypodermic  injection  when  5  to  10  minims  of  tincture  of  digitalis 
are  added.1  Spiritus  glonoini  (i.  e.  nitro-glycerin),  tTL  i  to  iv,  is  also 
a  reliable  heart  tonic  : 

3^.  Spts.  glonoini,  ttlv  ; 

Alcohol,  3j. 

M.     S.  —  One  or  two  hypodermic  syringefuls  @  twenty  minims. 


Strychnine  has  a  powerful  effect  on  respiration.2  Injection  of 
of  a  solution  of  1  part  of  camphor  in  4  parts  of  olive  oil  into  the  deltoid 
or  vastus  externus  muscle  is  efficacious  and  harmless.3  Faradization 
of  the  diaphragm  may  occasionally  prove  useful. 

Against  the  collapse  caused  by  cocaine  have  been  recommended  in- 
halation of  nitrite  of  amyl,  subcutaneous  injections  of  ether  or  caffeine, 
or  a  warm  or  cold  infusion  of  coffee  by  the  mouth. 

1  The  injection  of  camphor  dissolved  in  acetic  ether,  used  in  several  hospitals  of 
this  city  as  well  as  elsewhere,  ought  to  be  discarded,  as  it  in  several  cases  has  pro- 
duced paralysis. 

8  Horatio  C.  Wood  of  Philadelphia  has  made  special  experiments  in  regard  to  the 
effect  of  drugs  during  anesthesia,  and  laid  the  results  before  the  International  Medi- 
cal Congress  in  1890  (Abstract  in  Practice,  Feb.,  1891,  p.  58-59).  According  to 
him,  alcohol  is  ineffective  in  small  doses  and  dangerous  in  large.  Nitrite  of 
amyl,  caffeine,  and  atropine  are  of  little  or  no  use.  Ammonia  has  some  little  influ- 
ence on  the  heart.  He  recommends  digitalis  for  the  heart  and  strychnine  for  the 
respiration. 

3  H.  C.  Coe,  The  New  York  Polyclinic,  vol.  i.  No.  1,  p.  20. 


TREATMENT  IN  GENERAL. 


211 


FIG.  177. 


Both  ether  and  chloroform  are  very  apt  to  cause  vomiting.  The 
patient  should,  therefore,  not  have  any  solid  food  the  day  of  the  opera- 
tion. AVhen  she  vomits,  she  should  be  turned  on  her  side,  so  as  to 
give  the  ejected  masses  a  free  outlet  and  prevent  their  entrance  into 
the  larynx.  After  the  operation  she  should  only  have  hot  water  or 
ice-water  in  teaspoonful  doses  to  relieve  her  thirst  until  all  nausea 
has  stopped.  A  little  black  coffee  is  grateful,  and  seems  to  have  a 
good  effect  on  the  stomach.  If  vomiting  continues,  I  give,  with  ex- 
cellent effect,  the  following  mixture  : 

ty.  Acidi  hydrocyanic!  dil.,  3ss ; 
Acidi  citrici, 

Sodii  bicarbon,  ad.  5\j  ; 

Syr.  rubi  Idaei,  BSS; 

Aquae,  ad  svj. — M. 

Sig.  A  tablespoouful  every  one,  two,  or  three  hours. 

Common  Instruments,  and  their  Use. — Some  instruments  are  so 
generally  useful  that  they  are  needed  for  nearly  all  gynecological 
operations,  and  should  always  be  on 
hand.  Such  are  a  uterine  sound  (p. 
152),  bivalve  and  univalve  specula 
(pp.  144  and  145),  a  vaginal  depressor 
(p.  147),  tenacula,  volsellse,  sponge- 
holders,  knives,  scissors,  several  pairs 
of  artery-forceps  (p.  184),  needles,  a 
needle-holder,  counter-pressure-hook, 
suture-twister,  and  suture-shield.  With 
some  of  these  we  are  already  acquainted 
from  the  chapter  on  Examination.  In 
regard  to  the  others  I  shall  make  a  few 
remarks. 

Weight  Speculum. — For  certain  ope- 
rations which  are  best  performed  with 
the  patient  in  the  dorsal  posture,  such 
as  trachelorrhaphy  and  vaginal  hyster- 
ectomy, it  is  a  great  advantage  to  have 
a  speculum  that  is  held  in  place  by  its 
own  weight,  and  at  the  same  time  can 
be  easily  removed  and  replaced  (Fig. 
177). 

Vaginal    Retractor's.  —  Besides    the 
specula    and    depressors    described    in 
speaking  of  how  to   make   an  exam- 
ination, lateral  retractors,  such  as  Schroeder's  (Fig.  178)  or  Engc-1- 
mann's,  are  often  needed  in  operations  in  the  dorsal  position. 


Garrlgues'  Weight  Speculum 


212 


DISEASES  OF  WOMEN. 


Tenacula. — A  tenaculum  is  a  sharp-pointed  steel  hook  with  handle, 
which  should  be  made  of  one  piece  of  metal.     Two  shapes  of  hooks 


FIG.  178. 


Schroeder's  Vaginal  Retractor. 


are  most  convenient :  one  is  simply  bent  so  as  to  form  a  little  less 
than  a  right  angle ;  in  the  other  the  point  has  a  second  flexure  in  the 
direction  of  the  handle  (Fig.  179). 


FIG.  179. 


Emmet's  Tenaculum. 


Tenacula  are  used  to  put  tissue  on  the  stretch,  to  lift  up  tissue  to 
be  cut,  to  manipulate  silver  sutures,  etc. 


FIG.  180. 


Volsella. 


A  volsella  (Fig.  180)  is  a  pair  of  forceps,  each  blade  of  which  ends 
in  a  double  hook.     It  is  used  for  seizing  and  pulling  tissue.     For 


FIG.  181. 


Pean's  Traction-forceps. 


vaginal  hysterectomy  Plan's  traction-forceps  (Fig.  181)  is  excellent 
almost  indispensable. 


an 


TREATMENT  IN  GENERAL. 


213 


A  tenaculum-forceps  is  a  modified  volsella  with  single  or  double 
hooks,  and,  as  a  rule,  of  more  slender  build. 

A  tissue-forceps  (Fig.  182)  is  a  pair  of  forceps  with  side  teeth,  con- 
venient for  holding  a  strip  of  tissue  while  cutting  it  off. 


FIG.  182. 


Tissue-forceps. 


A  sponge-holder  (Fig.  183)  should  be  made  of  one  piece  of  nickel- 
plated  steel.     It  is  a  rod  with  a  handle  at  one  end,  and  divided  at  the 


FIG.  183. 


Sims's  Sponge-holder.    (At  a  a  piece  of  the  shaft  is  left  out.) 

other  into  two  halves  with  teeth,  which  are  brought  together  with  a 
ring.  Four  sponge-holders  are  needed.  Often  long  pressure-forceps 
or  stout  dressing-forceps  are  preferred,  especially  when  pads  are  used 
instead  of  sponges  (p.  196). 

Knives  are  used  much  less  than  in  general  surgery.  A  medium- 
sized  scalpel  is  about  all  that  is  needed. 

Scissors  are  in  most  cases  used  to  great  advantage  as  cutting  instru- 
ments. They  cause  less  hemorrhage  than  knives,  are  more  expedi- 
tious, and  can  do  more  delicate  work.  Often  they  are  used  closed  as 
a  blunt  instrument.  The  chief  shapes  needed  are  straight,  curved  on 
the  flat,  and  knee-bent  on  the  edge.  They  must  for  most  purposes 
have  long  shanks. 

When  a  surface  is  to  be  pared  a  tenaculum  is  passed  into  the 
mucous  membrane  at  the  end  nearest  to  the  operator  and  at  the  lowest 
part  of  the  field  to  be  denuded,  so  as  to  avoid  having  blood  running 
over  the  upper  part  that  is  to  be  denuded  later.  The  mucous  mem- 
brane is  lifted  a  little,  and  the  scissors  are  made  to  cut  off  a  thin  strip 
of  tissue  under  the  tenaculum  in  such  a  way  that  the  tenaculum  stays 
in  the  loosened  strip.  When  once  the  strip  is  cut  loose,  it  is  often 
more  convenient  to  exchange  the  tenaculum  for  a  tissue-forceps.  The 
strip  should  be  cut  of  as  uniform  breadth  and  thickness  as  possible, 
and  from  one  end  of  the  surface  to  be  denuded  to  the  other.  If  this 
is  wider  than  the  strip,  one  or  more  similar  strips  are  cut  off  parallel 


214 


DISEASES  OF   WOMEN. 


to  the  first,  taking  great  care  not  to  leave  any  part  undenuded.  While 
this  is  being  done  the  denuded  surface  is  kept  free  from  blood  by  irri- 
gation or  sponging.  Especial  care  is  also  taken  to  get  a  regular  line 
of  incision  all  around  the  pared  surface  without  any  projecting  tongues 
or  receding  bays. 

Pressure-forceps,  of  lighter  or  heavier  construction,  are  put  on 
bleeding  vessels.  If  it  is  a  large  vessel  that  spurts,  the  pressure- 
forceps  takes  simply  the  place  of  the  old  artery-forceps  before  the 
vessel  is  secured  by  means  of  a  ligature,  but  on  small  vessels  the 
pressure  exercised  by  the  pressure-forceps  suffices  within  a  few  min- 

Fio.  184. 


Needles  :  a,  short  straight  round  ;  b,  long  straight  round;  c,  trocar- pointed  straight;  d,  semi- 
curved,  crescent-ground  (Sims's  fistula-needle) ;  e,  semi-curved,  trocar-pointed  (Emmet's 
cervix-needle);  /,  curved,  crescent-ground;  g,  curved,  trocar-pointed  ;  h,  i,  old-fashioned 
strongly  curved  surgical  needles  with  three  edges ;  j,  semicircular  Hagedorn  needle ;  k, 
half-curved  Hagedorn  needle  ;  I,  fishhook-shaped  needle. 

utes  to  arrest  the  hemorrhage  permanently,  so  that  no  ligature  is 
needed. 

Needles. — A  variety  of  needles  (Figs.  184  and  185)  are  used,  and 
special  kinds  made  for  gynecological  work  have  in  certain  operations 
been  found  preferable  to  the  old-fashioned  needles  used  in  general 
surgery.  We  use  straight,  more  or  less  curved,  round,  trocar- 
pointed,  crescent-ground,  Hagedorn,  and  handled  (sharp-pointed  or 
dull)  needles.  Common  English  sewing-needles,  short  and  long,  may 
be  used  in  the  vulva  and  the  vagina.  They  are  harder  to  push  through 
the  tissues,  but  make  only  a  round  hole,  which,  on  account  of  the  elas- 
ticity of  the  penetrated  tissue,  closes  round  the  suture.  The  same  kind 
of  needles  are  also  curved,  which  makes  it  easier  to  push  them  in  a 
curved  line.  But  where  the  tissues  offer  much  resistance  it  is  neces- 
sary to  make  the  round  needle  cutting  near  the  point  by  grinding  it 


TREATMENT  IN  GENERAL. 


215 


so  as  to  form  a  crescent-shaped  surface  with  two  cutting  edges,  or 
three  sharp  edges  like  the  point  of  a  trocar  or  a  spear.  Hagedorn's 
needles  are  flat  from  side  to  side,  with  a  straight  cutting  edge  near 
the  point.  They  have  a  very  large  eye,  which  makes  them  particu- 
larly useful  when  catgut  is  used.  When  the  suture  inserted  with 
Hagedorn's  needles  is  tightened,  the  edges  of  the  wound  made  by 
the  needle  are  drawn  together  from  side  to  side,  instead  of  being 
pulled  apart,  as  when  a  needle  is  used  that  cuts  at  right  angles  to  the 
direction  of  the  suture. 

In  order  to  avoid  turning  or  breaking  of  the  curved  needles  when 
grasped  by  the  needle-holder,  the  part  nearest  the  eye  should  be 

FIG.  185. 


Needles  with  Handles :  a,  slightly  curved,  sharp-pointed  or  dull ;  b  and  c,  strongly  curved, 
dull ;  d,  Marcy's  needle,  sharp-pointed,  with  eye  from  side  to  side. 


straight  and  flat.    For  operations  on  the  intestines  long  English  cam- 
bric needles,  about  No.  7,  are  used. 

^  Needle-holder. — For  all  these  needles  a  needle-holder  is  needed. 
Sims's  (Fig.  186),  that  has  rings  like  scissors,  is  indispensable  for  fine 
work  in  the  vagina,  especially  operations  for  fistula;  Hagedorn's 
(Fig.  187)  is  adapted  to  his  needles,  and  Crosby's  can  be  used  for 
any  needle,  opens  by  mere  pressure,  and  is  easy  to  disinfect  (Fig. 
188). 

As  a  rule,  the  needle-holder  should  be  applied  to  the  needle  just  in 


216 


DISEASES  OF   WOMEN. 


front  of  the  eye,  for  if  the  latter  is  comprised  in  the  grasp  of  the 
forceps,  the  needle  is  very  liable  to  break. 


FIG.  186. 


Situs's  Needle-holder. 


Much  time  is  saved  and  a  good  adaptation  more  easily  obtained  by 
using  handled  needles  (Fig.  185),  but  in  order  to  be  strong  enough  to 


FIG.  187. 


Hagedorn's  Needle-holder. 


pass  through  resistant  tissues  they  must  be  made  so  thick  that  they 
make  a  large  hole,  which,  however,  immediately  contracts,  and,  there- 


FIG.  188. 


Crosby's  Needle-holder. 


fore,  is  without  importance  if  the  patient  is  anesthetized.     When  only 
slightly  curved  and  ending  in  a  sharp  point,  these  needles  are  partic- 


TREATMENT  IN  GENERAL.  217 

ularly  useful  for  closing  wounds  in  the  perineum  or  the  abdominal 
Avail,  and  are  often  called  perineum-needles  (Fig.  185,  a).  They  have 
the  eye  near  the  point,  and  are  threaded  after  having  been  pushed 
through  the  tissue.  A  blunt  needle  of  this  kind  is  used  in  ovariotomy 
and  similar  operations,  and  will  be  described  later. 

Instead  of  a  needle  and  needle-holder  a  ligature-carrier  (Fig.  189) 
may  sometimes  be  used  with  advantage.     It  is  a  half  sharp-pointed 

FIG.  189. 


Cleveland's  Ligature-carrier. 

curved  forceps,  between  the  jaws  of  which  the  ligature  is  seized  and 
carried  around  the  tissue  to  be  ligated. 

Ligatures. — For  ligatures  is  used  silk  or  catgut  (pp.  201-204). 
They  should  be  tied  in  the  so-called  square  knot,  and,  as  we  have  seen 
above,  catgut  requires  sometimes  an  additional  knot.  In  most  opera- 
tions the  ends  are  cut  short  and  the  ligature  left  in  the  body. 

Under  particular  circumstances  (see  Lupus  Vulvas,  Fecal  Fistulas, 
Fibroids  of  the  Uterus,  etc.)  the  elastic  ligature  of  rubber  is  used. 
It  consists  of  solid  round  strings  varying  in  diameter  from  less  than 
-fa  up  to  ^  inch,  or  in  rubber  tubing  twice  as  thick.  Rubber  soon 
loses  its  elasticity,  and  in  order  to  be  reliable  a  ligature  of  this  sub- 
stance must  be  rather  new.  It  is,  however,  said  to  preserve  its  elas- 
ticity for  a  whole  year  or  more  by  being  kept  in  a  4-per-thousand 
solution  of  bichloride  of  mercury  in  alcohol.1 

Sutures. — The  chief  materials  used  for  .sutures  are  silk,  catgut, 
silver  wire,  silkworm  gut,  and  kangaroo  tendon  (pp.  201—205).  Silk 
is  generally  tied  in  a  surgical  knot,  for  which  catgut  and  silkworm  gut 
are  not  pliable  enough.  Where  the  surgical  knot  cannot  be  used,  an 
assistant  may  by  pressure  prevent  the  suture  from  opening  while  the 
second  knot  is  being  tied.  Silk  sutures  may  be  left  in  the  abdominal 
wall  for  a  week. 

Silk  sutures  placed  near  a  drainage-tube  or  a  tampon,  from  which 
septic  material  may  come,  are  apt  to  become  secondarily  infected. 
In  order  to  avoid  this  they  should  not  be  used  in  such  places,  but 
preference  given  to  silver  wire  or  silkworm  gut,  which  do  not  absorb 
fluids. 

1  Fasola  and  Martinelty,  Cenlralblalt  f.  Gynak.,  1891,  Nov.  24,  p.  50(5. 


218 


DISEASES  OF  WOMEN. 


Silk  may  be  rendered  more  resistant  to  infection  by  immersing  it 
during  the  operation  in  a  mixture  containing  iodol  : 


Glycerini, 

Alcohol, 

Iodol, 


ad  5  parts  ; 
1  part. 


In  the  vagina  I  have  often  left  silk  sutures  for  a  month  without 
causing  suppuration  or  cutting  through.  When  silk  or  silkworm 
gut  is  to  be  removed,  the  ends  are  seized  with  a  pair  of  pressure- 
forceps  and  slightly  lifted  ;  the  end  of  one  blade  of  a  pair  of  sharp- 
pointed  scissors  is  inserted  under  the  suture,  and  the  latter  is  cut  close 
up  to  the  skin  or  mucous  membrane  on  one  side,  in  order  to  prevent 
that  part  of  the  suture  that  has  been  exposed,  and  is  often  dirty,  from 
being  drawn  through  the  stitch-canal. 

Silver  wire  may  be  fastened  directly  in  the  eye  of  a  needle  —  e.  g. 
in  stitching  a  torn  perineum  —  but  for  most  plastic  operations  it  is 
necessary  to  use  a  thread  of  silk,  linen,  or  hemp  as  a  wire-carrier. 
Both  ends  of  a  linen  thread  (No.  70)  two  feet  long  are  passed  from 
the  same  side,  one  after  the  other,  through  the  eye  of  the  needle,  and 
then  the  two  ends  together  are  tied  with  the  loop  on  the  other  side 
of  the  needle,  so  as  to  form  a  half  knot  just  behind  it.  If  the  free 
ends  are  made  about  4  inches  long,  we  get  a  loop  about  8  inches  long. 
A  piece  of  silver  wire  10  or  12  inches  long  is  bent  at  a  distance  of  f 
of  an  inch  from  one  end  under  a  sharp  angle,  which  is  done  by  seizing 
it  in  a  needle-holder  and  bending  it  close  up  to  the  edge  of  the 
instrument.  At  the  same  time  we  straighten  the  wire  and  ascer- 


FIG.  190. 


Two  Denuded  Surfaces,  showing  where  the  sutures  He. 

tain  that  there  are  no  kinks  in  it  by  sliding  the  nails  of  the  thumb 
and  middle  finger  down  its  full  length.  The  hook  thus  formed  at 
one  end  of  the  silver  wire  is  passed  through  the  loop  of  the  thread 
and  given  a  little  twist,  so  as  to  prevent  it  from  coming  off.  •  When 
one  pared  surface  is  to  be  applied  against  the  other,  the  needle  is,  as 


TREATMENT  IN  GENERAL. 


219 


a  rule,  inserted  about  a  quarter  to  half  an  inch  from  the  outer  edge 
of  one  of  the  denuded  surfaces,  carried  deep  in  under  the  same,  and 
pushed  out  just  on  the  inner  line  between  pared  and  unpared  tissue, 
reinserted  at  the  corresponding  point  on  the  other  side,  and  pushed 
out  a  quarter  or  half  an  inch  beyond  the  pared  surface  (Fig.  190). 
When  the  point  of  the  needle  emerges  from  the  tissue,  a  dull  hook, 
much  like  a  button-hook  and  called  a  counter-pressure  hook  (Flo:. 
191),  is  inserted  under  the  point  and  pressed  against  the  tissue,  while 

FIG.  191. 


Emmet's  Counter-pressure  Hook. 

the  operator  pushes  the  needle  farther  in.  Next  he  takes  the  needle- 
holder  off  from  the  posterior  part  of  the  needle  and  seizes  the  point 
above  the  counter-pressure  hook,  and  pulls  the  needle  through. 
When  the  thread  has  been  drawn  through  under  both  surfaces,  it  is 
suddenly  pulled  on,  so  as  to  jerk  the  silver  wire  through  the  tissue. 
When  the  wire  is  pulled  halfway  through,  the  hook  is  detached  from 
the  loop,  and  one  end  of  the  wire  is  made  to  form  a  slip-knot  round 
the  other,  and  this  suture  is  temporarily  put  aside  until  all  have 
been  inserted. 

Only  if  there  is  much  hemorrhage,  it  may  exceptionally  be  neces- 
sary to  close  a  suture  immediately  after  passing  it. 

When  all  the  sutures  are  in  place  we  proceed  to  close  them,  begin- 
ning with  the  uppermost.  The  slip-knot  is  pushed  down  and  the  free 
end  pulled  farther  out,  taking  care  not  to  cut  the  tissue  with  the  wire, 
until  the  loop  is  reduced  to  a  little  over  an  inch  in  length.  The  two 
ends  are  now  seized  below  the  slip-knot  with  the  wire-twister  (Fig. 
192),  the  long  free  end  cut  off,  the  suture  drawn  taught  and  shouldered 
— /.  e.  bent  with  a  tenaculum  at  the  point  that  will  come  to  lie  just 

FIG.  192. 


Emmet's  Wire-twister. 


at  the  line  of  union  when  the  edges  are  brought  together  (Fig.  193). 
Next,  the  suture-shield  (Fig.  1 94)  is  placed  around  both  wires  and 
pushed  gently  down  to  the  tissue.  The  wires  are  now  bent  against 
the  sharp  inner  edge  of  the  shield,  and  turned  round  until  the  twisted 
part  thus  formed  just  reaches  the  shield. 

This  is  the  nicest  point  in  the  whole  procedure.     If  you  do  not 


220 


DISEASES  OF  WOMEN. 


FIG.  193. 


twist  enough,  the  suture  will  be  loose  and  not  bring  the  denuded 
edges  in  contact ;  and  if  you  twist  too  much,  you  will  strangle  the 
tissue  included  in  the  loop,  and  the  suture  will 
cut  through. 

While  the  end  is  yet  held  with  the  twister 
the  shield  is  withdrawn,  a  tenaculum  pressed 
against  the  wire  just  where  the  twisted  part 
ends,  and  the  latter  bent  to  a  side  at  right 
angles  to  the  line  of  union.  At  a  distance  of 
half  an  inch  the  tenaculum  is  pressed  against 
the  twisted  wire,  another  right  angle  formed, 
and  the  end  cut  off  at  this  point.  The  wire 
should  lie  quite  flat  against  the  skin  or  mucous 
membrane.  When  there  are  many  sutures,  it 
is  sometimes  an  advantage  to  turn  them  alter- 
nately to  either  side.  The  number  of  sutures 
should  always  be  counted  at  the  end  of  the 
operation  and  marked  in  the  history  of  the 
case,  as  they  sometimes  become  so  imbedded  that  they  are  hard  to 
find.  I  have  seen  a  forgotten  silver  suture  work  its  way  into  the 
bladder  and  form  the  nucleus  of  a  stone,  and  have  heard  of  over- 
looked silk  sutures  causing  septicemia  and  death. 

FIG.  194. 


Shouldering  Wire  Suture : 
a,  twisted  suture  bent  to 
a  side  and  cut  short ;  b, 
shouldered  suture. 


Sims's  Suture-shield. 

In  most  operations  silver  sutures  are  left  in  for  nine  days,  but  on 
the  cervix  some  leave  them  for  a  month,  in  order  to  ensure  reliable 
union  or  to  save  a  perineum  operated  on  at  the  same  time.  When 
the  time  comes  for  removing  them, the  end  is  seized  with  the  twister; 
the  suture  is  pulled  gently  up  until  a  minute  triangular  space  appears 
between  the  wires  and  the  tissue;  one  point  of  the  wire-scissors,  a 
strong  pair  of  curved  scissors  with  rather  sharp  points,  is  inserted 
under  one  of  the  wires,  which  should  be  cut  close  up  to  the  point 
where  it  enters  the  tissue ;  and  finally  the  twisted  end  is  pulled  in 
the  direction  of  this  same  point,  by  which  we  press  the  newly-united 
edges  against  one  another,  instead  of  pulling  them  apart.  Slight 
irregularities  caused  by  the  imbedding  of  the  wires  disappear  soon 
after  their  removal. 

The  kind  of  suture  most  used  in  gynecological  work  is  the  inter- 
rupted. Rarely  the  quitted  suture  is  required.  The  continuous,  suture 
is  often  used  in  laparotomy,  in  bringing  together  the  edges  of  the 
peritoneum  in  closing  the  abdominal  wall,  or  after  the  removal  of 


TREATMENT  IN  GENERAL. 


221 


tumors  or  organs.     Some  use  it  also  much  in  plastic  operations  for 
lacerated  cervix,  cystocele,  or  prolapse  of  the  uterus.     A  particular 

FIG.  195. 


Beginning  of  a  Catgut  Tier-suture  (A.  Martin). 


modification  of  this  suture   is  the   so-called   continuous   tier-suture 
(Fig.  195). 

Suppose  an  oval  denudation  has  been  made  on  the  anterior  vaginal 
wall.  The  needle,  armed  with  a  catgut  thread  a  yard  long,  is  carried 
through  both  edges  and  under  the  whole  pared  surface  from  the 
operator's  right  side  to  the  left,  near  the  upper  end  of  the  wound. 
The  catgut  is  pulled  through  until  within  about  three  inches  from 
the  end,  and  tied  in  a  knot  as  for  an  interrupted  suture.  The  free 
end  is  seized  and  drawn  up  with  a  pressure-forceps.  Then  several 
turns  are  made  in  the  same  way  below  the  first,  but  with  a  continuous 
suture,  always  drawing  the  thread  taut.  When  the  tension  becomes 
too  great,  the  needle  is  not  carried  under  the  whole  wound-surface, 
but  only  under  the  part  of  it  lying  nearest  the  median  line,  thus 
placing  a  deep  tier  at  the  bottom  of  the  wound.  When  the  operator 
reaches  the  lower  narrow  part  of  the  oval,  he  comprises  again  the 
edges  in  the  suture.  If  necessary,  a  second  tier  of  buried  sutures 
may  be  placed  over  the  first  (Fig.  196),  avoiding  interference  with 
it,  and  finally  the  superficial  tier  is  inserted.  The  best  way  of  knot- 


222 


DISEASES  OF  WOMEN. 


ting  the  suture  is  by  pulling  the  free  end  so  far  out  that  it  can  be 
tied  together  with  the  loop  carrying  the  needle.  This  method  of 
suturing  is  expeditious,  and  has  the  advantage  of  bringing  broad 
surfaces  in  contact  with  each  other. 

Interrupted  sutures  may  also  be  placed  in  tiers  above  one  another 
— e.  g.  in  closing  the  abdomen  after  laparotomy. 

FIG.  196. 


Second  Deep  Row  of  Tier-Sutures  (A.  Martin). 

Chain-suture  is  used  to  secure  thick  pedicles,  and  will  be  described 
under  Ovariotomy. 

Sponging  and  Irrigation. — During  most  plastic  operations  very 
small  sponges  or  pads  on  sponge-holders  are  needed,  and  the  assistant 
should  press  the  sponge  very  gently  against  the  bleeding  place,  with- 
out rubbing  it,  and  he  should  always  keep  those  points  clean  where 
the  needle  is  to  be  inserted  or  pushed  out.  In  operations  performed 
in  the  dorsal  decubitus  irrigation  with  some  hot  antiseptic  fluid  or  hot 
sterilized  water  may  advantageously  be  substituted  for  sponging  (pp. 
182  and  199);  and  under  all  circumstances  it  is  advisable  to  irrigate 
the  wound  before  closing  the  sutures  and  to  remove  all  clots.  The 
smoother  and  cleaner  the  cut  surfaces  are,  the  sooner  they  will  grow 
together  by  first  intention. 


TREATMENT  IN  GENERAL.  223 

How  to  Clean  and  Disinfect  Instruments. — Instruments  should  be 
boiled  in  a  solution  of  soda  before  every  operation  (p.  199).  After  an 
operation  they  should  be  scrubbed  with  soap  or,  better,  sapolio  and 
water,  and  nail-brush,  rinsed  with  clear  water,  and  wiped  perfectly 
dry  with  at  least  two  towels.  During  the  operation  they  should  be 
immersed  in  sterilized  water  or  a  2J  per  cent,  solution  of  carbolic  acid. 

Selection  of  Instruments. — In  preparing  for  an  operation  the  ope- 
rator or  his  assistant  should  carefully  go  through  the  different  steps 
of  the  operation  in  their  mind,  and  take  out  all  instruments  that  are 
sure  to  be  used ;  but,  besides,  they  ought,  within  reasonable  limits,  to 
prepare  themselves  for  the  unexpected  by  having  such  instruments 
in  readiness  as  may  be  required  under  certain  eventualities,  and  by 
having  more  than  one  of  the  most  indispensable  instruments,  such  as 
knives,  scissors,  needles,  pressure-forceps,  etc. 

5.  Combination  of  Operations. — If  several  operations  are  needed 
on  one  patient,  it  is,  as  a  rule,  best  to  perform  them  at  different  sit- 
tings ;  but  as  this  would  sometimes  take  more  time  and  cost  more 
money  than  the  patient  can  afford,  it  may  become  necessary  to  per- 
form two  or  more  in  one  sitting.  This  ought,  however,  only  to  be 
done  when  the  single  operation  does  not  require  much  time  nor  cause 
much  shock,  for,  other  things  being  equal,  the  danger  increases  with 
the  length  of  the  operation.  A  torn  cervix,  a  cystocele,  and  a  lace- 
rated perineum  may  all  be  operated  on  in  one  sitting;  likewise 
shortening  of  the  round  ligaments  and  perineorrhaphy ;  but  if  lap- 
arotomy  and  a  vaginal  or  perinea!  operation  are  required,  it  is 
better  to  do  the  laparotomy  first  and  the  other  a  week  later.  I 
prefer  to  follow  the  same  principle  in  regard  to  the  cervix,  and  post- 
pone the  other  operations  until  the  sutures  are  removed,  for  a  sec- 
ondary hemorrhage  may  occur  or  menstruation  come  on  prematurely, 
as  happens  so  often ;  or,  as  I  have  seen  once  in  a  very  scrofulous 
patient,  the  whole  cervical  portion  may  ulcerate,  and  the  necessary 
measures  for  the  diagnosis  or  treatment  may  frustrate  the  operations 
performed  on  the  walls  of  the  vagina.1 

After-treatment. — If  there  is  no  danger  of  shock,  the  best  way  is 
to  let  the  patient  sleep  after  the  operation  until  she  wakes  of  her  own 
account ;  but  if  there  is  shock,  it  is  better  to  rouse  her  by  aspersion 
of  cold  water,  shaking,  talking,  etc. 

If  she  vomits,  the  measures  recommended  in  treating  of  anesthesia 
(p.  204)  should  be  taken. 

For  the  thirst,  frequently  repeated  teaspoonful  doses  of  hot  water 
are  often  good,  but  in  other  cases  nothing  is  like  small  quantities  of 
ice-water.  Ice  itself  does  not  quench  thirst.  An  injection  of  tepid 
water  into  the  rectum  has  sometimes  proved  useful  (p.  170). 

1  How  far  some  operators  go  in  combination,  and  yet  get  good  results,  may  be  seen 
in  a  paper  by  Edebohls,  Amer.  Jour.  Med.  Sci.,  Sept.,  1892,  p.  262. 


224  DISEASES  OF  WOMEN. 

No  food  is  given  as  long  as  nausea  continues.  As  a  rule,  a  fluid 
diet  of  peptonized  milk,  buttermilk,  kumyss,  matzoon,  beef-tea,1  and 
oatmeal  gruel  may  be  begun  the  day  after  the  operation.  ^Nothing 
solid  should  be  taken  until  the  bowels  have  been  moved,  which  in 
perineal  operations  is  done  on  the  fourth  day,  and  in  laparotomies  and 
vaginal  hysterectomies  on  the  third,  by  giving  castor  oil,  laxol,  com- 
pound licorice  powder  or  sodium  sulphate.  (See  Ovariotomy.) 

Pulse,  temperature,  and  respiration  should  be  marked  graphically 
on  charts,  so  that  the  surgeon  may  judge  of  the  condition  at  the  first 
glance.  The  nurse  should  also  keep  a  record  of  food  taken,  urine 
excreted,  and  movements  of  the  bowels. 


CHAPTER  III. 
INTERNAL  TREATMENT. 

FEW  gynecological  diseases  can  be  cured  by  internal  treatment 
alone,  but,  combined  with  external  treatment,  the  internal  is  a  valu- 
able and  often  indispensable  adjuvant. 

The  reader  is,  of  course,  supposed  to  be  conversant  with  general 
therapeutics.  He  will  ever  bear  in  mind  that  the  body  from  the  ver- 
tex to  the  sole  forms  one  system,  all  parts  of  which  are  most  inti- 
mately connected ;  he  will  watch  for  symptoms  pointing  to  disorders 
in  any  division  of  the  body ;  and  in  his  treatment  of  gynecological 
cases  he  will  make  such  modifications  as  are  called  for  by  the  condi- 
tions of  other  organs  or  the  constitution  in  general. 

Food  and  Drink. — Most  gynecological  patients  are  suffering  from 
anemia,  and  often  from  anorexia  at  the  same  time.  Attention  must 
therefore,  first  of  all,  be  paid  to  their  diet.  They  should  be  encour- 
aged to  eat  as  much  albuminoid  food  as  possible,  and,  by  taking  six 
small  meals  a  day  instead  of  the  usual  three  more  copious  ones,  much 
can  be  done  to  increase  the  amount  of  food  taken  every  day.  The 
physician  should  give  as  precise  orders  as  possible  in  regard  to  time, 
quality,  and  quantity  of  meals,  and  look  to  a  proper  variety  in  order 
to  avoid  disgust.  Mild  alcoholic  drinks,  such  as  beer,  Johann  Hoff's 
malt  extract,  Rhine  wine,  Moselle  wine,  French  or  Hungarian  claret, 
Burgundy,  vin  Mariani,  port,  or  tokay,2  should  be  taken  with  meals 
unless  especially  contraindicated. 

1  Monsqnera's  beef-jelly  is  excellent  for  the  purpose. 

2  Where  economy  is  an  object  the  strong  California  wines,  such  as  port,  sherry, 
angelica,  and  tokay,  are  to  be  recommended.     Good  wines  can  be  obtained  for  50 
cents  a  bottle,  and  superior  kinds  are  sold  for  $1.     These  wines  are  certainly  much 
to  be  preferred  to  the  cheap  mixtures  often  sold  as  imported  wines.     I  have  been 
particularly  pleased  with  the  "  Sunset "  wines. 


TREATMENT  IN  GENERAL.  225 

Weir  Mitchell's  rest  cure,  in  which  the  patient  is  removed  from 
her  friends,  put  to  bed,  fed  by  a  nurse  to  the  limit  of  her  digestive 
powers,  and  treated  with  massage  and  electricity,1  may  be  indicated 
in  exceptional  cases,  but,  as  a  rule,  gynecological  patients  should  be 
encouraged  to  take  as  much  exercise  in  the  open  air  as  they  can  with- 
out increasing  their  sufferings. 

If  the  patient  cannot  digest  her  food,  she  should  take  pepsin  and 
hydrochloric  acid  after  each  meal : 

3^.  Pepsi  nee,  3\]  ; 

Acid,  hydrochlor.  dilut.  3\j  ; 

Syr.  aurant.,  3ss ; 

Aqua?,  ad  Sviij. — M. 

Sig.  Shake  well.     A  tablespoonful  after  meals. 

I  have  also  found  Parke,  Davis  &  Co.'s  pepsin  cordial  very  bene- 
ficial. 

In  severe  cases  of  indigestion  rectal  alimentation  may  even  become 
necessary.2 

Very  commonly  gynecological  patients  suffer  from  constipation 
and  need  some  aperient.  A  heaping  teaspoonful  of  Carlsbad  salts3 
or  sulphate  of  sodium,  dissolved  in  a  tumblerful  of  hot  water  and 
taken  on  an  empty  stomach  in  the  morning,  often  effects  a  cure  in 
the  course  of  six  weeks.  A  heaping  teaspoonful  of  compound  licorice 
powder,  taken  in  the  evening,  gives  a  passage  the  next  morning,  and 
many  like  that  powder.  As  a  rule,  I  combine  the  aperient  with  a 
tonic  by  giving  Blaud's  pills  with  aloes : 

!fy.  Ferri  sulph., 

Potass,  carb.,  da  3ij  ; 

Aloes  Socotrinae,  gr.  v  to  xv ; 

Extr.  gentianse  co..  q.  s. 

Ft.  pil.,  No.  Ix. 
Sig.  Three  pills  three  times  a  day,  after  meals. 

Sometimes  nausea  or  vomiting  call  for  symptomatic  treatment. 
They  should  be  treated  with  bismuth,  for  instance : 

Tfy.  Bismuthi  subnitr.,  gij  ; 

Magnesise  carb., 

Sacchari,  ad.  §ss. — M. 

Sig.  A  heaping  teaspoonful  three  times  a  day,  between  meals  ; 

1  S.  Weir  Mitchell,  Fat  and  Blood,  and  how  to  Make  them,  2d  ed.,  Philadelphia 
1878. 

2  An  important  paper  on  this  subject,  by  Henry  F.  Campbell  of  Augusta,  Ga.,  is 
found  in  Trans.  Amer.  Gyn.  Soc.,  1878,  vol.  iii.  p.  268,  et  seq. 

3  The  artificial  salt  seems  to  be  just  as  good,  and  costs  only  one-fourth  of  the  im- 
ported. 

15 


226  DISEASES  OF  WOMEN. 

or  Liq.  iodi  co.  (Tflj  every  two  hours);  creosote  (iflj  every  three  hours); 
ac.  hydrocyan.  dilut.  (flliij  every  one  to  three  hours);  tinct.  nuc.  vora. 
(ttliij  every  three  hours),  each  diluted  with  a  tablespoonful  of  water; 
or  cocaine  hydrochlorate  (gr.  J  every  two  or  three  hours) ;  or  cerium 
oxalate  (gr.  iij  to  v,  t.  i.  d.,  in  pills). 

Tonics  are  nearly  always  needed,  especially  iron,  quinine,  strych- 
nine, arsenic,  and  phosphorus.  I  do  not  know  of  any  better  tonic  than 
the  solution  of  ferrous  malate  (American  Pharmaceutical  Manufactur- 
ing Company)  and  the  compound  tincture  of  cinchona,  equal  parts. — 
M.  Sig.  A  teaspoonful  three  times  a  day. 

Another  valuable  combination  is  the  following: 

1^.    Strychninse  sulph.,  gr.  j  ; 

Ferri  et  quininae  citrat.,        3ij  ; 
Syr.  aurant,  5ss ; 

Aquae,  ad  |iij. — M. 

Sig.  A  teaspoouful  in  a  wine-glass  full  of  water,  three  times  a 
day,  after  meals. 

Plain  Blaud's  pills  are  also  excellent.  If  a  malarial  element  is 
present,  full  doses  of  quinine  and  other  antiperiodics  are  required. 

In  carnogen,  the  extract  of  red  bone-marrow,  given  in  teaspoonful 
doses,  we  have  a  new  and  powerful  remedy  against  anemia. 

In  tympanites,  so  often  accompanying  gynecological  diseases, 
strychnine  answers  an  excellent  purpose. 

Anodynes  are  sometimes  indispensable,  but  they  should  only  be 
used  for  a  short  time  and  in  as  small  doses  as  will  suffice.  Magen- 
die's  solution  of  morphine,  4  to  8  drops  three  times  a  day ;  tincture 
of  opium,  15  drops;  or  suppositories  with  1  grain  of  opium  every 
three  hours,  are  the  most  common  anodynes.  Hydrobromate  of 
hyoscine,  gr.  ^,  has  been  much  praised  of  late.  I  find  phenacetiu, 
in  doses  of  vii  ss  grains,  repeated  after  one  hour,  and  if  needed  a 
second  time  after  three  hours,  has  an  excellent  effect  in  relieving 
pelvic  pain. 

Extract  of  conium  in  the  dose  of  1  or  2  grains,  L  i.  d.,  is  also  good, 
lodoform  or  aristol,  5  grains,  in  suppositories,  t.  i.  d.,  often  dulls  pain. 

Among  sedatives,  the  bromides  of  potassium,  sodium,  and  ammo- 
nium, single  or  combined,  are  often  required.  An  embrocation  with 
chloroform  (1  part)  and  olive  oil  (3  parts)  gives  at  least  temporary 
relief  in  the  troublesome  backache  so  generally  complained  of. 

If  the  patient  is  troubled  with  insomnia,  it  has  to  be  met  with  one 
of  the  many  hypnotics  chemistry  has  offered  us  in  late  years.  I  have 
been  particularly  pleased  with  sulphonal  (gr.  x),  chloralamid  (gr.  xlv), 
or  trional  (gr.  xv). 

Resolvents  are  often  called  for  in  chronic  inflammations.  The  most 
important  are  iodine,  gold,  and  mercury.  We  have  spoken  in  another 


TREATMENT  IN  GENERAL.  227 

place  (pp.  170  and  188)  of  the  application  of  tincture  of  iodine  to 
the  vaginal  roof  and  the  abdominal  wall.  Internally,  iodine  is  best 
given  as  iodide  of  potassium,  gr.  viij-x,  t.  i.  d.  The  chloride  of 
sodium  and  gold  has  seemed  to  me  to  have  a  decided  effect,  espe- 
cially in  chronic  oophoritis.  It  is  given  in  the  dose  of  gr.  ^  to  £, 
t.  i.  d.,  after  meals.  The  bichloride  of  mercury  (gr.  y1-^,  t.  i.  d.)  has 
been  recommended  in  chronic  metritis. 

Hemostatics. — In  acute  hemorrhages  from  the  womb,  menstrual  or- 
mtermenstrual,  ergot  is  the  best  drug  (Extr.  ergotse  fl.  3j,  t.  i.  d.,  or 
so-called  ergotin,  gr.  ij,  t.  i.  d.}.  It  works  by  causing  contraction 
of  the  unstriped  muscle-fibers  composing  the  bulk  of  the  womb  and 
those  found  in  the  walls  of  the  arteries.  It  is  also  useful  in  subin- 
volution,  chronic  metritis,  active  or  passive  hyperemia,  in  intramural 
and  submucous  fibroids,  but  not  in  polypi,  in  which  it  is  apt  to 
increase  the  hemorrhage. 

In  chronic  cases  cotton-root  is  in  my  experience  superior  to  all 
other  remedies,  whatever  the  cause  of  the  hemorrhage  may  be.1  The 
fluid  extract  is  not  so  efficacious  as  a  decoction  prepared  fresh  every 
morning  by  boiling  three  heaping  teaspoonfuls  of  rasped  cotton-root 
bark  with  one  pint  of  water  for  a  quarter  of  an  hour,  during  which 
one-half  of  the  fluid  evaporates.  It  is  then  strained,  and  one-third 
taken  cold  three  times  a  day  (1^.  Gossypii  radicis  corticis  raspati,  siv). 
This  decoction  not  only  checks  hemorrhage  when  present,  but  seems 
to  have  a  tonic  influence  on  the  uterus  and  the  general  health.  The 
patients  may  take  it  for  months,  only  interrupting  its  use  from  two 
to  four  days  in  the  beginning  of  menstruation.  I  have  found  that 
in  fibroids  it  even  takes  the  concomitant  pain  away,  besides  checking 
the  hemorrhage  and  arresting  the  growth  of  the  tumor.  It  works, 
like  ergot,  by  causing  contraction  of  the  muscular  tissue  of  the  uterus, 
and  is  often  used  in  the  South  to  produce  abortion. 

Another  uterine  hemostatic  that  I  sometimes  have  seen  help  when 
the  two  first  named  had  failed  is  the  mistletoe  (I$j.  Extr.  visci  albi 
fl.  3ij.  Sig.  A  teaspoonful  three  times  a  day). 

Bromides  are  good  when  the  cause  of  the  hemorrhage  is  nervous 
excitement.  If  malaria  is  at  the  bottom  of  it,  quinine,  followed  by 
small  doses  of  arsenic  (Liq.  potass,  arsenitis,  gtt.  iij  to  v,  t.  i.  (/.),  is 
indicated.  Arsenic  is  also  recommended  in  the  menorrhagia  of  grow- 
ing girls  and  young  women,  and  that  occurring  at  the  climacteric. 
In  syphilitic  patients  mercury  is  to  be  prescribed. 

Digitalis  is  recommended  for  the  passive  hyperemia  consequent  on 
weakness  of  the  heart  or  mitral  insufficiency.  Opium  becomes  a 
hemostatic  by  subduing  excitement.  Cannabis  Indica  operates  prob- 
ably in  a  similar  way  (Bf.  Tinct.  cannabis  Indicse,  Ij. — Sig.  20-40 

1  Garrigues,  The  Post-Graduate,  Jan.,  1887,  vol.  ii.  No.  2,  p.  117,  and  Xew  Yorker 
Medicinische  Presse,  Nov.,  1886,  vol.  ii.  No.  6,  p.  231. 


228  DISEASES  OF  WOMEN. 

drops  three  times  a  day).  It  has  been  especially  extolled  in  the  hem- 
orrhages of  the  climacteric.  Witch-hazel  has  been  accorded  a  high 
position  on  the  scale  of  uterine  hemostatics  in  passive  engorgement 1 
(!^.  Extr.  hamamelis  fl. — Dose,  from  a  few  drops  up  to  2  drachms). 

Among  astringents  are  used  gallic  acid  (gr.  v  to  xv  in  pills  or 
powder,  t.  i.  d.),  and  alum  (gr.  x  to  xx,  i.  i.  d.,  especially  in  the  form 
of  alum-whey,  prepared  by  boiling  2  drachms  of  alum  with  a  pint 
of  milk,  and  straining. — Dose,  a  wineglassful,  containing  15  grains  of 
alum). 

Other  drugs  that  are  recommended  for  uterine  hemorrhage  are 
Viburnum  prunifolium  (Extr.  fl.,  3j,  t.  i.  </.) ;  hydrastis  Canadensis 
(Extr.  fl.,  gtt.  xx,  t.  i.  d.\  or  hydrastiuinse  hydrochloras  (gr.  %,  in  a 
capsule,  four  times  a  day) ;  terebinthina  Chieusis  (gr.  vj,  t.  i.  c/.2) ; 
tinct.  capsici  (5  drops  in  a  tablespoouful  of  water  every  hour) ;  smut 
of  Indian  corn  (Extr.  ustilaginis  maidis  fl.,  3j,  t.  i.  d.),  and  the  root 
of  Caulophyllum  thalictroides  (3j-3ij  of  the  infusion  or  decoction 
made  with  an  ounce  of  the  root  to  a  pint  of  water,  or  3J— 3y  of  the 
tincture  made  with  four  ounces  to  the  pint),  which  both  cause  uterine 
contraction ;  the  nettle  (Urtica  urens  and  U.  dioica,  as  decoction, 
3j  to  Oj  of  water. — Dose,  a  cupful  several  times  a  day).  Chlorate 
of  potassium,  given  together  with  ergot,  is  also  regarded  with  much 
favor. 

In  cases  of  uterine  hemorrhage  the  bowels  should  be  kept  open, 
so  as  to  avoid  congestion  of  the  pelvic  organs.  Sulphate  of  sodium, 
the  old  "  sal  mirabile  Glauberi,"  a  heaping  teaspoonful  dissolved  in 
a  little  hot  water  every  four  hours  till  effective,  answers  a  good 
purpose. 

When  we  see  an  exsanguinated  person,  we  are  tempted  to  give 
iron,  but  this  drug  should  be  carefully  avoided  during  uterine  hem- 
orrhages, which  I  invariably  have  found  increase  when  any  chalyb- 
eate is  used.  Even  in  the  interval  between  the  hemorrhages  it  has 
to  be  used  tentatively,  as  it  sometimes  increases  the  amount  of  blood 
lost  at  the  next  flow.  The  same  applies  to  alcoholic  drinks.  I  pre- 
fer under  such  circumstances  first  to  use  cotton-root,  ergot,  cinchona, 
and  sulphuric  acid,  combined  with  local  treatment  and  non-alcoholic 
malt  preparations,  until  the  tendency  to  bleeding  has  been  overcome. 

Antipyretics. — In  acute  cases  there  are  often  indications  for  reducing 
the  temperature.  If  ice-bags  and  sponging  with  equal  parts  of  cold 
water  and  alcohol  do  not  suffice,  recourse  is  had  to  antipyretic  drugs, 
such  as  quinine  (in  10-grain  doses),  salicylate  of  sodium  (gr.  xv),  anti- 
pyrine  (gr.  x),  phenacetin  (gr.  vii  ss),  or  antifebrin  (gr.  v),  repeated 
with  two  hours'  interval. 

1  Chauncey  D.  Palmer  of  Cincinnati,  O.,  Trans.  Amer.  Gyn.  Soc.,  1887)  vol.  xii. 
p.  182. 

2  J.  R.  Chadwick,  Boston,  Trans.  Amer.  Gyn.  Soc.,  xii.  p.  88. 


TREATMENT  IN  GENERAL. 


229 


CHAPTER   IV. 
ELECTRIC  TREATMENT. 

ELECTRICITY  is  of  great  value  in  gynecology.  The  different  kinds 
of  electricity  and  differently  constructed  machines  and  batteries  have 
very  different  effects,  and  must,  therefore,  be  considered  separately. 
We  distinguish  between  franklinism,  faradism,  and  galvanism,  and,  as 
a  subdivision  of  the  last  named,  galvano-cauterization. 

1.  Franklinism,  or  frictional  electricity,  is  produced  by  rubbing  a 
glass  plate  against  cushions  covered  with  amalgam.     The  patient  may 
be  insulated  by  sitting  on  a  stool  with  glass  feet,  her  body  more  or 
less  filled  with  electricity,  and  sparks  drawn  from  her  by  approaching 
a  metal  rod  to  different  parts  of  her  body.     Another  way  of  using 
frictional  electricity  is  by  means  of  sparks  and  shocks  from  a  Leyden 
jar.     This  kind  of  electricity  is  little  used,  and  can  hardly  have  any 
other  effect  than  as  a  nerve-stimulant  and  counter-irritant  in  hyper- 
esthesia  and  neuralgic  pain. 

2.  Faradism,  or  inductional  electricity, 
is   produced  by  leading  the   electricity 
generated  in  one  or  more  voltaic  cells, 
usually  composed  of  zinc   and   carbon 
immersed  in  a  fluid  containing  bichro- 
mate of  potassium,  sulphuric  acid,  and 
water,  through   a   short  coil   of  coarse 
insulated  copper  wire  called  the  primary 
coil,  in  such  a  way  that  the  current  is 
broken  and  closed  at  short  intervals.  The 
effect  is  much  enhanced  by  placing  a  bun- 
dle of  varnished  wires  of  soft  iron  inside 
of  the  coil.     Outside  of  the  primary  coil 
is  another  called  the  secondary  coil,  which 
consists  of  a  much  longer  and  finer  insu- 
lated copper  wire.     The  current  going 
through  the  first  coil  is  called  the  pri- 
mary current,  and  that  induced  in  the 
second  the  secondary  current. 

The  primary  current  produces  muscu- 
lar contraction,  but  the  secondary,  having 
the  same  effect  in  a  higher  degree,  is  in 
more  general  use  for  this  purpose. 

One  electrode  may  be  applied  in  the 
uterus  or  in  the  vagina,  the  other  on  the 
abdominal  Avail  over  the  fundus  of  the 
uterus,  or  both  poles  may  be  combined  in  one  uterine  or  vaginal  elec- 
trode (Fig.  197).     The  advantages  of  the  bipolar  method  are  that  it 


Apostoli's  Bi-polar  Uterine  and  Va- 
ginal Excitors:  1,  small  uterine; 
2,  medium  uterine ;  3,  larire  ute- 
rine :  4,  vaginal,  used  in  the  ute- 
rus after  confinement. 


230  DISEASES  OF  WOMEN. 

is  less  painful,  the  sensitive  skin  not  being  enclosed  in  the  current, 
and  that,  consequently,  a  much  stronger  current  can  be  borne. 

If  the  primary  current  goes  through  a  thick  and  short  wire,  it  has 
a  great  quantity  of  electricity ;  and  if  the  secondary  current  is  in- 
duced in  a  very  long  and  thin  wire,  it  acquires  a  high  degree  of  ten- 
sion.1 Such  a  current  of  tension  has  great  power  in  subduing  pain 
(ovaralgia,  abdominal  pain  in  hysterical  women,  vaginismus,  and  pain 
arising  from  pelvic  inflammations).  It  is  also  an  emmenagogue. 

The  faradic  current  is,  as  a  rule,  applied  three  times  a  week,  some- 
times daily ;  each  sitting  lasts  from  ten  to  thirty  minutes.  The  elec- 
trodes should  be  applied  first,  and  then  the  current  turned  on  very 
slowly,  the  patient's  feeling  serving  as  a  guide  as  to  the  strength 
applied.  At  the  end  the  strength  of  the  current  is  again  gradually 
decreased  until  it  stops  before  the  electrodes  are  withdrawn.  The 
reason  for  so  doing  is  that  the  vulva  is  much  more  sensitive  than  the 
vagina  and  uterus,  and  that  a  strong  current  is  more  endurable  when 
it  is  increased  and  decreased  gradually  than  when  it  begins  and  ceases 
suddenly.  The  cervix  is  also  much  more  sensitive  than  the  body  of 
the  womb. 

3.  Galvani&m,  or  chemical  electricity,  is  produced  in  a  so-called 
battery,  a  combination  of  jars  containing  the  elements  and  the  exciting 
fluids.  As  strong  currents  often  are  needed,  it  is  necessary  to  have 
a  powerful  battery.2 

One  of  the  electrodes  is  applied  to  the  abdomen  or,  exceptionally, 
to  the  back.  It  ought  to  be  very  large,  so  as  to  distribute  the  current 
over  a  large  surface,  and  thereby  diminish  its  density.  Apostoli's3 
external  electrode  consists  of  wet  clay4  in  a  bag  of  muslin  10  or  12 

1  Lapthorn  Smith  recommends  a  primary  coil  of  No.  14  or  16,  25  yards  long,  with 
a  secondary  coil  No.  40,  a  mile  long  (Med.  News,  Jan.  25,  1890).     Rockwell  has  con- 
structed an  apparatus  which  is  made  by  the  Jerome  Kidder  Manufacturing  Company, 
820  Broadway,  New  York  (New  York  Med.  Jour.,  May  13,  1893).     With  the  latest 
improvements  this  battery  consists  of  a  fixed  coil  of  No.  21  wire,  62  to  65  feet  long, 
for  the  primary  current,  and  a  movable  secondary  coil,  operated  by  a  rack-move- 
ment.    The  total  length  of  this  secondary  coil  is  7,962  feet,  with  the  following  sub- 
divisions: 726  feet  of  No.  21  wire,  tapped  at  252  and  474  feet;  2,574  feet  of  No.  32 
wire,  tapped  at  1,224  and  1,350  feet ;  and  4,662  feet  of  No.  36  wire,  tapped  at  1,632 
and  3,030  feet.     The  machine  is  provided  with  a  circle-switch,  allowing  the  selection 
of  the  total  length  of  the  wire,  or  any  part,  or  any  subdivision  of  any  part,  of  the 
coil,  and  with  a  rheostat  for  modifying  minutely  the  strength  of  the  current. 

2  A  battery  of  forty  large  Leclanche"  cells,  each  with  an  electro-motor  power  of  one 
and  a  half  volts,  or  one  of  thirty  acid  cells,  each  producing  two  volts,  is  much  used  here. 

8  Electricity  had  been  used  in  gynecology  as  long  as  it  has  existed  as  a  special 
branch  of  medicine,  and  important  work  had  been  done  in  this  line  also  in  this 
country  by  Kimball  of  Lowell,  Mass.,  Ephraim  Cutter  of  New  York,  J.  N.  Freeman 
and  John  Byrne  of  Brooklyn,  N.  Y.,  and  others.  But  since  1884,  Apostoli  of  Paris 
has  given  this  kind  of  treatment  such  an  impetus  by  opening  new  and  large  fields 
for  it,  and  introducing  great  improvements  in  its  application,  that  his  name  is  on 
all  lips,  and,  therefore,  this  historical  note  may  be  pardoned  as  an  exception.' 

4  In  order  to  prevent  it  from  getting  dry,  it  is  a  good  plan  to  add  glycerin  to  the 
water  (Lapthorn  Smith  of  Montreal,  Amer.  Jour.  Obstet.,  Aug.,  1889,  vol.  xxii.  p.  798). 


TREATMENT  IN  GENERAL.  231 

inches  long  and  6  or  8  inches  wide.  It  has  the  advantage  of  adapt- 
ing itself  perfectly  to  the  surface ;  but  it  has  the  drawback  of  soiling 
physician,  patient,  and  office,  and  may,  therefore,  advantageously  be 
replaced  by  Enc/elmann's  electrode,  which  consists  of  a  flexible  plate 
of  lead  7  by  6  inches,  perforated  with  many  holes  and  covered  with 
punk  and  chamois ;  or  Martin's  electrode,  wrhich  is  a  nickel-plated 
concave  plate,  8  inches  in  diameter,  covered  with  a  membrane  and 
containing  a  pint  of  warm  water.  The  skin  should  be  well  moist- 
ened before  the  current  is  turned  on,  as  otherwise  a  resistance  is 
formed  by  the  horny  epidermis.  It  is  an  advantage  to  have  the 
cutaneous  electrode  immersed  in  plain  warm  water.  To  add  salt  is 
not  always  good,  although  it  aids  in  overcoming  the  resistance  of  the 
skin ;  but  when  salt  is  used  the  sensibility  increases,  and  consequently 
we  cannot  use  so  strong  currents  as  without  it.1  The  inner  electrode 
is,  as  a  rule,  applied  in  the  cavity  of  the  uterus  all  the  way  up  to  the 
fundus. 

Apostoli's  intra-uterine  electrode  is  made  of  platinum  and  shaped 
like  a  uterine  sound,  with  a  movable  sheath  of  celluloid.  This  sound 
has  the  advantage  of  being  incorrodible.  It  is,  however,  a  disadvan- 
tage that  it  is  stiff,  has  a  tube  hard  to  clean,  and  is  very  expensive. 
To  obviate  this,  sounds  have  been  constructed  in  which  only  the  last 
two  inches  are  made  of  platinum,  while  the  remainder  is  a  flexible 
gum  catheter  with  a  wire  in  the  middle.  Aluminium  cannot  re- 
place platinum,  as  it  becomes  corroded.  Finding  it  sometimes  diffi- 
cult or  impossible  to  introduce  the  flexible  sound,  I  have  had  one 
made  with  a  tip  of  platinum,  No.  9  French,  2  inches  long,  mounted 
on  a  brass  rod  covered  with  hard  rubber  (Fig.  198).  The  anterior 

FIG.  198. 


Garrigues'  Intra-uterine  Electrode. 

part  is  bent  like  a  sound,  the  posterior  end  split  for  the  introduction 
of  the  tip  of  the  rheophore.  This  electrode  is  very  easy  to  introduce 
and  to  keep  clean,  and  has  given  me  entire  satisfaction.2  The  burn- 
ing part  being  so  small,  it  must,  of  course,  gradually,  both  in  the  same 
sitting  and  at  different  sittings,  be  applied  to  different  parts  of  the 
endometrium.  Dr.  Goelet  has  had  stiff  iutra-uterine  electrodes  made 
of  wrought  iron  and  steel  by  a  process  of  treatment  which  renders  the 
metal  non-corrosive  and  non-attackable  by  acids  for  a  considerable 
length  of  time.3 

1  A.  H.  Buckmaster,  New  York,  "  The  Galvanic  Treatment  of  Fibro-m yomatn," 
Brooklyn  Med.  Jour.,  Nov.  and  Dec.,  1888. 

2  It  was  made  by  Waite  &  Bartlett,  142  East  Twenty-third  street,  New  York. 

3  A.  H.  Goelet,  The  Medical  News,  June  22,  1889. 


232  DISEASES  OF  WOMEN. 

The  stiff  electrode  should  be  introduced  without  speculum  after 
disinfecting  the  vagina.1 

If  the  inner  pole  is  applied  to  the  vaginal  roof,  a  ball  of  metal  or 
gas-carbon,  one-half  to  three-quarters  of  an  inch  in  diameter,  mounted 
on  a  hard-rubber  stem  with  central  wire,  may  be  employed ;  but  a 
thick  layer  of  cotton  should  be  wound  around  the  bulb  and  made 
thoroughly  wet.  By  so  doing  we  avoid  burning  the  vagina. 

The  current  is  led  from  the  battery  to  the  electrodes  by  means  of 
rheophores,  flexible  cords  of  fine  copper  wire  covered  with  gutta- 
percha  and  silk,  with  metal  tips  at  the  ends,  which  are  easily  adapted 
and  kept  in  place  by  a  set-screw  or  the  elasticity  of  a  cleft  in  the 
electrode. 

To  measure  the  strength,  or  so-called  intensity,  of  the  current  a 
mUliamperemeter  is  needed,  a  kind  of  galvanometer,  the  scale  of  which 
should  show  at  least  250  milliamperes. 

In  order  to  be  able  to  turn  the  current  on  and  off  very  gradually 
a  collector,  or  a  rheostat,  is  used.  The  collector  is  a  differently  con- 
structed metal  contrivance  which  allows  us  to  use  as  many  and  as  few 
cells  of  a  battery  as  we  wish.  It  ought  to  be  so  arranged  as  to  en- 
able the  operator  to  include  or  exclude  one  element  at  a  time.  The 
rheostat  is  a  bottle  half  full  of  water,  into  which  dip  two  carbon 
plates  connected  with  the  zinc  pole  of  the  battery.  Between  the  two 
is  a  third  carbon  plate  connected  with  the  carbon  pole  of  the  battery, 
bevelled  at  its  lower  end  and  ending  in  a  platinum  point.  This  plate 
can  be  moved  up  and  down  by  means  of  a  ratchet.  When  it  is  out 
of  the  water  there  is  no  current,  and  by  gradually  immersing  it  the 
current  becomes  stronger  until  the  full  strength  of  the  battery  is 
turned  on. 

The  current  coming  from  a  battery  may  be  used  as  a  constant  or  as 
an  interrupted  current.  The  latter  causes  a  shock  and  •  muscular  con- 
traction, but  is  more  or  less  painful,  and  with  strong  currents  even 
dangerous. 

By  using  large  and  wet  electrodes  we  chiefly  get  the  interpolar 
effect,  which  is  that  of  electrolysis.  By  using  small  and  dry  electrodes 
we  chiefly  obtain  the  polar  effect,  which,  when  the  current  is  strong 

1  In  order  to  have  the  chemical  cauterizing  effect  of  the  intra-uterine  electrode,  it 
has  been  calculated  that  it  should  present  a  surface  of  1  square  centimeter  for  each 
25  milliampSres  (F.  H.  Martin,  Trans.  Amer.  Gyn.  Soc.,  1888,  vol.  xiii.  p.  275). 
Apostoli  has  a  series  of  seven  intra-uterine  electrodes  made  of  gas-carbon,  which 
conducts  readily,  is  little  subject  to  the  corroding  action  at  the  positive  pole,  and  may 
be  had  at  small  expense.  The  length  is  the  same  in  all,  1  inch,  but  the  thickness 
varies  from  5  to  12  millimeters  (J  to  i  inch)  in  diameter.  They  are  screwed  on  an 
insulated  metallic  stem,  the  insulating  sheath  of  which  has  a  circular  groove  for 
every  inch.  This  electrode  is  used  in  irregular  and  deep  uterine  cavities,  and  by 
withdrawing  it  from  groove  to  groove  the  cauterizing  effect  is  extended  from  one 
part  to  the  other  (Apostoli,  "Novelties,"  Brit.  Med.  Ass.,  August,  1888,  reprint, 
p.  26). 


TREATMENT  IN  GENERAL.  233 

enough,  becomes  a  chemical  cauterization.  By  combining  a  large  wet 
electrode  on  the  skin  with  a  small  dry  electrode  in  the  uterus  we 
avoid  burning  the  skin  and  obtain  the  chemical  cauterization  of  the 
uterus. 

Experiments  on  living  animals  have  shown  that  when  a  galvanic 
current  of  50  M.  is  applied  to  the  intestine  of  a  dog,  the  same  be- 
comes blanched.  When  it  is  applied  to  the  heart,  and  the  part  en- 
compassed between  the  poles  is  examined  under  the  microscope,  the 
stria)  of  the  muscular  fibrillse  are  found  in  a  granular  condition — a  sign 
of  beginning  disintegration.1 

That  the  molecules  are  moved  by  the  galvanic  current  can  even 
be  seen  in  a  physical  experiment.  When  a  vessel  is  divided  into 
two  compartments  by  a  porous  partition,  and  the  compartments  are 
filled  to  the  same  height  with  water,  and  a  galvanic  current  is  led 
through  them,  the  water  rises  in  that  compartment  in  which  the 
negative  pole  is.  This  electric  osmosis,  or  so-called  cataphoresis,  may 
be  used  for  introducing  drugs,  such  as  cocaine  or  iodide  of  potassium, 
into  the  body  by  applying  a  solution  of  them  to  the  anode.2 

Different  Qualities  of  the  Poles. — The  two  poles  of  the  battery  have 
different  physical  and  physiological  effects.  The  positive  pole  attracts 
acids,  while  alkalies  collect  at  the  negative.  The  eschar  produced  by 
the  positive  pole  is  dry ;  that  at  the  negative  is  softer,  larger,  and  lets 
the  galvanic  current  penetrate  through  it.  The  positive  is,  therefore, 
used  against  hemorrhage  and  leucorrhea,  the  negative,  where  it  is  de- 
sirable to  draw  blood  to  the  interior  of  the  uterus  and  for  galvano- 
puncture.  The  negative  pole  has  a  more  pronounced  denutritive 
effect.  But  if,  in  spite  of  these  general  rules,  the  expected  effect  is 
not  obtained,  it  is  advisable  to  try  the  other  pole,  and  in  the  course  of 
the  treatment  of  the  same  case  it  is  often  indicated  to  change  poles 
according  to  the  changed  circumstances. 

Apostoli's  Method. — The  operation  may  be  performed  in  the  pa- 
tient's home  or  in  the  physician's  office.  Sexual  connection  should 
be  forbidden. 

Before  operating  with  a  battery  with  collector,  the  physician  should 
try  the  battery  in  order  to  ascertain  that  there  is  no  break  in  the  cur- 
rent, which  would  cause  a  shock.  This  may  be  done  by  including 
one  cell  after  the  other  in  the  current  and  watching  the  deviation  of 
the  needle  of  the  milliampe'rerneter. 

The  patient  should  remove  her  corset.8  She  lies  on  her  back,  with 
her  knees  drawn  up.  If  there  are  any  erosions  of  the  skin,  they 
must  be  covered  with  collodium  or  paper  before  the  electrode  is  placed 

1  Buckmaster,  /.  c.,  pp.  12-14. 

2  Frederic  Peterson,  "  Electric  Cataphoresis  as  a  Therapeutic  Measure,"  JST.  1". 
Med.  Jour.,  April  27,  1889. 

3  In  using  Engelmann's  electrode  it  is  enough  to  open  the  lower  part  of  it. 


234  DISEASES  OF   WOMEN. 

over  them.  Strict  antisepsis  is  used  in  regard  to  hand,  vagina,  uterus, 
and  internal  electrode.  The  current  should  not  be  turned  on  until 
all  pain  caused  by  the  introduction  of  the  intra-uterine  electrode  has 
ceased.  Then  it  is  turned  on  slowly,  so  that  it,  takes  half  a  minute  to 
a  minute  before  the  full  strength  is  reached.  In  the  beginning  some 
pain  is  felt  on  the  skin,  due  to  the  resistance  oifered  by  the  epidermis. 
Then  we  wait  till  it  has  ceased  before  increasing  the  strength  of  the 
current.  The  strength  of  current  used  varies  according  to  the  nature 
of  the  case  and  the  sensitiveness  of  the  patient.  As  a  rule,  an  in- 
tensity of  little  less  than  100  milliamperes  is  used,  but  when  there  is 
a  subacute  inflammation  of  the  parts  situated  near  the  uterus,  and  in 
hysterical  patients,  only  40  to  50  milliamperes  can  be  tolerated.1 
Under  all  circumstances  it  is  advisable  not  to  go  too  far  at  the  first 
sitting,  but  to  stop,  say,  at  50  M.  There  must  never  be  any  severe 
pain  felt  in  the  uterus.  In  large  uteri  the  intensity  must  be  increased 
or  the  surface  of  the  intra-uteriue  pole  diminished.  The  current  is 
kept  up  from  five  to  ten  minutes,  in  most  cases  only  five.  At  the 
end  it  is  turned  off  as  slowly  as  it  was  turned  on.  The  vagina  is 
again  disinfected,  and  the  patient  is  directed  to  use  antiseptic  injec- 
tions the  following  days. 

The  sittings  are,  as  a  rule,  repeated  on  out-door  patients  once  a 
week,  but  in  more  urgent  cases  twice  a  week  :  in  private  practice  the 
applications  are  made  two  or  three  times  a  week.  But  hemorrhage 
may  call  for  treatment  every  day ;  and,  on  the  other  hand,  where 
there  is  perimetric  inflammation,  it  may  not  be  tolerated  more  than 
once  in  eight  or  ten  days.  As  a  rule,  the  applications  are  made  in 
the  intermenstrual  period,  but  if  there  is  severe  hemorrhage  it  may 
be  necessary  to  operate  immediately.  Twenty,  thirty,  or  more  sittings 
may  be  needed  to  effect  a  cure. 

Immediate  Effect. — Often  some  uterine  colic  is  felt  immediately 
after  the  treatment,  and  may  last  from  a  few  minutes  to  several  hours, 
or  even  till  the  next  day.  Sometimes  the  patient  may  lose  a  little 
dark  blood,  and  on  the  following  days,  when  the  eschar  is  being 
thrown  off,  there  is  always  some  sero-purulent  discharge.  Exception- 
ally, even  enormous  amounts  of  a  watery  fluid  are  discharged  through 
the  vagina.  It  is  therefore  by  no  means  rare  that  the  symptoms,  on 
the  whole,  get  worse  during  the  first  five  or  six  sittings  before  im- 
provement begins.  Sometimes  fever  and  other  signs  of  inflammation 
may  necessitate  the  temporary  interruption  of  the  galvanic  treatment. 

Chemical  Galvano-cauterization  of  the  Cervix. — Apostoli  has  con- 
structed a  special  bipolar  electrode  of  carbon,  to  be  used  for  cauteriz- 

1  When  it  is  desirable  to  use  strong  currents  in  hysterical  patients,  they  should  go 
to  bed  an  hour  before  treatment  and  take  a  full  dose  of  morphine  and  atropine,  and, 
if  that  is  not  enough,  chloroform  is  used.  The  current  is  used  for  ten  minutes. 
The  patient  remains  in  bed  for  at  least  six  hours  after  the  treatment.  In  this  way 
200  to  400  milliampSres  have  been  tolerated  (F.  H.  Martin,  Med.  Neivs,  Jan.  25, 1890). 


TREATMENT  IN  GENERAL.  235 

ing  the  cervix.  It  is  used  with  strong  currents  (150  to  200  M.)  for 
a  very  short  time  (two  to  ten  seconds).  The  writer  has  obtained 
excellent  results  by  using  a  milder  current,  40  M.,  a  longer  time 
(five  minutes),  and  a  carbon  electrode  wound  with  very  little,  nearly 
dry  cotton,  forming  the  positive  pole,  while  the  negative  was  an 
Engelmann  electrode  applied  to  the  abdomen  (see  Chronic  Endo- 
metritis). 

Galvano-puncture. — If  a  tumor  is  situated  in  the  uterus  in  such  a 
way  that  the  sound  cannot  be  made  to  enter  the  uterine  canal,  galvano- 
puncture  is  used.  A  trocar-  or  lance-head-pointed  platinum  or  gold 
needle  is  pushed  through  the  vaginal  roof  into  the  tumor,  and  then 
connected  with  the  negative  pole  of  the  battery.  In  inserting  the 
needle  care  is  taken  to  feel  for  and  avoid  pulsating  arteries,  and  to 
push  in  such  a  direction  as  to  reach  the  uterus.  On  account  of  the 
anatomical  relation  to  the  bladder  such  punctures  cannot  be  made  in 
front,  but  only  behind  and  to  the  sides  of  the  cervical  portion  ;  and  in 
the  latter  locality  we  must  keep  clear  of  the  ureters  and  the  uterine 
artery.  Counter-pressure  is  made  on  the  fundus  through  the  abdom- 
inal wall.  A  fine  needle  should  be  used  and  introduced  without  spec- 
ulum. The  introduction  of  the  needle  may  be  much  facilitated  by 
making  it  the  negative  pole  of  a  mild  galvanic  current.  The  puncture 
is  made  on  the  point  where  the  uterus  bulges  most  into  the  vagina.  The 
needle  is  not  pushed  deeper  in  than  a  quarter  to  half  an  inch.  It  is 
either  used  to  form  a  communication  with  the  cervical  canal,  so  that, 
the  artificial  canal  once  made,  the  usual  galvano-cauterization  may  be 
performed  on  the  uterine  mucous  membrane,  or  goes  simply  into  the 
tissue  of  the  uterus  and  perhaps  a  tumor  situated  in  its  wall.  Hemor- 
rhage may  be  stopped  by  interpolar  action  alone,  without  cauterization 
of  the  mucous  membrane  of  the  uterus. 

Galvano-puncture  is  a  more  serious  interference  than  galvano-cau- 
terization of  the  inside  of  the  uterus,  and  should  not  be  repeated 
oftener  than  every  eight  or  fifteen  days.  It  has  to  be  repeated  several 
times  before  the  canal  remains  open.  It  may  be  combined  with  posi- 
tive or  negative  cauterization  according  to  indications.  Upon  the 
whole,  galvano-puncture  is  more  dangerous  than  other  methods  that 
will  be  described  in  treating  of  uterine  fibroids,  and  cannot  be  rec- 
ommended. 

Thermal  Galvano-cauterization. — The  thermal  galvano-cauterization 
differs  from  the  chemical  by  using  heat  as  the  therapeutic  agent.  It 
is  produced  by  another  kind  of  battery  especially  constructed  for  the 
purpose.  The  principle  is  to  produce  a  large  quantity  of  electricity, 
which,  being  led  through  a  comparatively  thin  platinum  wire,  that  offers 
great  resistance,  heats  the  wire  to  incandescence.  Two  sizes  of  wire 
are  used— a  thin  and  a  thick.  The  former  forms  a  loop  that  can  be 
drawn  round  and  through  a  cylindrical  body — e.  y.  the  cervix  uteri. 


236  DISEASES  OF  WOMEN. 

The  latter  is  shaped  into  knives  and  domes  for  cutting  and  burning.1 
By  means  of  these  galvano-cauteries  diseased  parts  may  be  excised 
without  loss  of  blood ;  but  in  order  to  obtain  this  the  knife  or  wire 
must  never  be  brought  to  a  white  heat,  and  they  should  be  carried 
slowly  and  interruptedly  through  the  part  to  be  severed.  The  knife 
should  be  applied  cold,  in  order  not  to  wound  the  vagina  while  intro- 
ducing it.  If  the  wire  loop  cannot  easily  be  applied,  a  furrow  may 
first  be  made  for  it  with  the  cautery  knife.  When  the  wire  has 
entered  the  submucous  tissue,  traction  may  be  made  with  a  volsella 
on  the  mass  to  be  removed,  so  as  to  give  to  the  cut  surface  the  shape 
of  a  hollow  cone. 

Thermal  galvano-cauterization  does  not  only  present  the  advantage 
over  other  cauteries  (p.  182)  that  it  can  be  applied  with  a  flexible 
loop,  but  it  has  less  radiating  heat,  and  is,  therefore,  less  liable  to 
scorch  the  surrounding  parts ;  it  seems  to  possess  a  power  of  modify- 
ing the  tissue,  even  at  some  distance  from  the  cut  surface,  by  diffusion 
of  the  electricity ;  and  it  has  a  powerful  antiseptic  effect,  which 
appears  clinically  in  the  remarkable  immunity  from  peritonitis,  cellu- 
litis,  and  septicemia  which  distinguishes  it  from  other  surgical  pro- 
cedures, and  has  been  proved  experimentally  by  direct  application  to 
germ-cultures. 

Where  there  are  large  masses  of  diseased  tissue  in  the  interior  of 
the  womb,  it  is  often  preferable  first  to  remove  some  of  them  with  the 
curette  before  using  the  galvano-cautery.  But  then  bleeding  must 
first  be  stanched  by  irrigation  with  creolin,  sponging,  and  the  appli- 
cation of  the  cautery  to  open  vessels.  After  that  every  part  of  the 
cavity  is  gone  over  repeatedly  with  the  dome-shaped  galvano-cautery, 
and  each  time  that  blood  oozes  from  the  seared  tissues  the  cavity  is 
to  be  sponged,  until  finally  it  is  charred  all  over.  The  ragged  bor- 
ders of  the  excavation  should  next  receive  attention,  and  no  raw  spot 
should  be  permitted  to  escape  the  cautery.  Finally,  the  cavity  and 
the  vagina  are  tamponed  with  iodoform  gauze  (pp.  179,  180). 

Metallic  Interstitial  Electrolysis. — Under  this  name  has  been  de- 
scribed a  procedure  which  in  reality  is  a  cataphoresis  of  drugs  formed 
by  the  electric  current  itself.  By  using  an  intra-uterine  electrode  of 
copper  connected  with  the  positive  pole  oxychloride  of  copper  is  formed, 
and  is,  by  the  electric  osmosis  or  cataphoresis,  driven  into  the  tissue. 
A  current  of  20  to  30  M.  is  used  for  from  five  to  ten  minutes.  Dur- 
ing the  application  the  electrode  should  be  kept  in  motion  in  order  to 
avoid  its  sticking  to  the  wall.  If  this,  however,  should  happen,  all 
that  is  needed  to  loosen  it  is  to  reverse  the  direction  of  the  current 

1  The  best  instrument  of  this  class  is  that  of  John  Byrne  of  Brooklyn,  H.  Y.,  who 
also  has  constructed  a  special  speculum  for  galvano-caustic  operations  (Clinical 
Notes  on  the  Electric  Cautery  in  Uterine  Surgery,  New  York,  1873,  and  Trans.  Amer. 
Qyn.  Soc.,  1892,  vol.  xvii.  pp.  42-46). 


TREATMENT  IN  GENERAL.  237 

for  a  few  minutes.  The  cervical  canal  must  be  patulous  for  subse- 
quent drainage,  and  it  should,  if  possible,  be  excluded  from  the  action 
of  the  copper.  This  treatment  has  proved  very  valuable  in  uterine 
hemorrhage  and  endometritis.  A  much  stronger  current,  80  to  100 
M.,  has  been  used  for  ten  minutes  in  the  cervix  for  gonorrhea.  After 
three  applications  all  gonococci  had  disappeared.  In  a  similar  way 
zinc  has  been  used.  It  forms  an  oxychloride,  which  has  the  property 
of  softening  the  tissue,  and  has  been  used  successfully  in  cases  of 
sclerosis  and  fibroid.  After  having  been  used,  these  corrodable  elec- 
trodes are  polished  with  emery  cloth.1 

1  A.  H.  Goelet,  The  Times  and  Register,  1893,  pt.  2,  p.  743. 


PART  VII. 

ABNORMAL  MENSTRUATION  AND  METRORRHAGIA. 

THE  normal  process  of  menstruation  has  been  considered  in  Part 
III.  (pp.  115-120).  This  process  is  subject  to  disturbances  which 
may  occur  in  very  different  gynecological  diseases  or  without  any 
affection  of  the  genitals.  It  may  be  absent  (amenorrhea)  or  scanty  ; 
the  bleeding  may  take  place  from  another  part  (vicarious  men- 
struation); it  may  be  painful  (dysmenorrhea) ;  it  may  begin  too 
early  in  life  (precocious  menstruation) ;  or  it  may  be  profuse  (men- 
orrhagia). 

Finally,  there  may  be  hemorrhage  from  the  uterus  at  other  times 
than  the  menstrual  period  (metrorrhagia). 


CHAPTER  I. 

AMENORRHEA. 

AMENORRHEA  is  the  absence  of  the  menstrual  flow.  This  may 
either  be  so  that  the  flow  had  begun  and  suddenly  stopped,  which  is 
called  suppression  of  menses,  or  so  that  it  does  not  come  on  at  all — 
amenorrhea  proper. 

1.  Suppression  of  Menses.  Etiology. — The  suppression  of  menses 
may  be  due  to  exposure  during  menstruation,  by  which  the  feet  or 
the  skin  becomes  wet  and  cold  (compare  p.  129) ;  to  emotions,  especially 
a  fright ;  or  to  the  appearance  of  an  acute  inflammation,  such  as  pneu- 
monia or  erysipelas. 

Symptoms. — The  symptoms  are  sometimes  slight  or  none,  and  the 
courses  reappear  at  the  next  period ;  but  sometimes  the  sudden  sup- 
pression of  the  menstrual  flow  gives  rise  to  acute  congestion  or  inflam- 
mation of  the  womb  or  the  appendages,  to  extravasation  of  blood 
into  the  peritoneal  cavity  or  the  pelvic  connective  tissue,  and  the 
amenorrhea  may  last  long  or  be  final. 

Treatment. — It  is  proper  to  try  to  bring  tne  flow  back  by  hot  appli- 
cations to  the  abdomen,  hot  hip-baths,  hot  vaginal  and  rectal  injec- 

238 


ABNORMAL  MENSTRUATION  AND  METRORRHAGIA.      239 

tions ;  but,  as  a  rule,  this  medication  succeeds  only  in  so  far  as  it 
relieves  pain.  The  same  is  accomplished  by  opiates. 

2.  Amenorrhea,  in  the  proper  sense  of  the  word,  is  the  condition 
in  which  the  menstrual  flow  fails  to  appear,  although  the  patient  has 
reached  the  proper  age  and  feels  as  if  she  would  be  relieved  by  its 
coming,  or  where  it  does  not  reappear  at  the  usual  period  in  persons 
who  have  already  menstruated. 

Etiology. — We  have  seen  above  that  menstruation,  as  a  rule,  is 
absent  during  pregnancy  and  lactation.  In  persons  who  have  never 
menstruated  the  cause  may  be  congenital  faulty  development :  absence 
of  the  ovaries  and  tubes;  absence  or  imperfect  development  of  the 
uterus,  such  as  a  rudimentary  or  infantile  uterus ;  absence  or  atresia 
of  the  vagina.  Often,  especially  in  young  servants,  the  cause  is  over- 
work, sometimes  combined  with  insufficient  food.  The  causes  may 
also  be  the  same  that  are  at  work  in  making  menstruation  stop  in 
those  who  have  already  menstruated.  A  common  cause  is  a  change 
of  climate  and  habits.  Thus  amenorrhea  is  often  found  in  women 
who  move  from  the  country  to  large  cities,  and  in  those  who  have 
recently  immigrated  from  Europe.  It  is  often  a  sequel  of  debilitating 
diseases,  such  as  anemia,  phthisis,  malaria,  typhoid  fever,  diabetes, 
or  chronic  mercurial  poisoning.  It  is  not  rare  in  insane  women 
and  morphiomaniacs.  It  is  sometimes  found  in  the  late  stage  of 
chronic  metritis,  in  inflammation  of  the  uterine  appendages,  in  cases 
of  malignant  disease  of  both  ovaries,  or  in  women  afflicted  with  a 
vesico-vaginal  fistula.  It  is  a  frequent  accompaniment  of  the  devel- 
opment of  obesity. 

About  the  effect  of  the  removal  of  the  uterine  appendages  see  p.  119. 

Symptoms. — The  symptoms  of  amenorrhea,  besides  the  absence  of 
the  flow,  may  be  insignificant,  but  it  is  quite  common  that  the  patient 
complains  of  headache,  flashing  heat,  heaviness  in  the  abdomen,  ner- 
vousness, nausea  or  vomiting,  and  sometimes  she  may  even  suffer  from 
convulsions  of  the  hysterical  or  epileptic  type.  If  the  lack  of  flow 
is  due  to  atresia  of  the  genital  canal,  the  fluid  accumulates  behind  the 
partition,  considerable  pain  is  experienced  at  each  recurrence  of  the 
menstrual  period,  and  a  tumor  is  felt  in  the  pelvis  corresponding  to 
the  distended  vagina,  uterus,  or  both.  The  abnormal  sensations 
occurring  at  the  time  of  the  menstrual  period  are  called  the  menstrual 
molimen. 

Diagnosis. — The  most  important  diagnostic  question  is  if  the  amen- 
orrhea might  not  be  physiological  and  due  to  pregnancy,  normal  <>r 
ectopic — i.  e.  outside  the  uterine  cavity.  In  this  respect  every  sign 
of  pregnancy  as  taught  in  works  on  obstetrics  must  be  thought  of, 
especially  the  early  signs,  such  as  the  softening  of  the  lower  uterine 
segment,  the  increased  diameter  of  the  uterus  in  the  antero-posterior 
direction,  morning  sickness,  and  small  tongues  of  brown  pigmentation 


240  DISEASES  OF  WOMEN. 

shooting  out  from  the  superior  external  circumference  of  the  areola, 
the  first  beginning  of  what  is  known  as  the  secondary  areola. 

In  ectopic  gestation  we  may,  besides  the  signs  of  pregnancy,  find  a 
tumor  outside  of  the  uterus  corresponding  in  size  to  the  duration  of 
the  amenorrhea. 

Treatment, — Idiopathic  amenorrhea  should  not  be  regarded  or 
treated  as  a  disease.  In  the  beginning  of  menstrual  life  it  is  quite 
common  that  a  period  or  two  are  skipped.  If  the  girl  is  otherwise 
well  no  treatment  is  called  for.  If  the  cause  of  the  amenorrhea  is 
anemia,  be  it  from  loss  of  blood,  from  defective  assimilation,  or  from 
wasting  diseases,  the  only  aim  should  be  to  ameliorate  the  general 
condition  by  proper  alimentation,  tonics  (p.  226),  moderate  exercise 
in  the  open  air,  horseback  riding,  mild  gymnastics,  or  massage. 
Aperients  have  some  influence  in  bringing  on  the  flow,  and  the 
one  most  credited  with  emmenagogue  power  is  aloes.  In  malaria 
quinine  and  arsenic  are  the  chief  remedies.  If  the  nervous  system 
is  upset,  bromides,  antipyrin,  or  phenacetin  is  very  useful.  Hot 
vaginal  and  rectal  injections,  warm  hip-baths,  warm  foot-baths  with 
or  without  mustard,  and  long,  warm  general  baths  will  sometimes 
bring  back  the  courses.  The  mere  introduction  of  the  sound  works 
as  a  stimulus  to  the  uterus,  and  may  have  the  same  effect.  Elec- 
tricity in  all  its  forms  (p.  229)  is  a  powerful  remedy,  especially 
bipolar  intra-uterine  faradization,  with  secondary  current,  and,  best 
of  all,  galvanism,  with  the  negative  pole  in  the  uterus. 

Besides  iron,  quinine,  strychnine,  and  aloes,  the  following  drugs  have 
more  or  less  well-founded  reputation  as  emmenagogues :  Manganese  in 
the  form  of  the  permanganate  of  potassium  or  the  binoxide  (gr.  ij  to 
iv,  t.  i.  d.) ;  chlorate  of  potassium  (gr.  v  to  xx,  t.  i.  d.)  in  combi- 
nation with  iron ;  santonin  (gr.  ij  or  iij,  t.  i.  d.) ;  oleum  sabinae  (tlfliij 
to  vj,  t.  i.  d.) ;  oleum  rutse  (Tfl,iij  to  vj,  t.  i.  d.} ;  oleum  tanaceti  (HI iij 
to  vj,  t.  i.  d.)  •  oleum  hedeomae  (ttlij  to  x,  t.  i.  d.)  or  a  warm  infusion 
made  of  the  herb ;  ergot  (p.  227) ;  radix  gossypii  (p.  227) ;  tinct. 
cantharidis  (lfl,x,  xx,  up  to  fej,  t.  i.  d.) ;  tinct.  hellebori  nigri  (Tltxx  to 
xl,  t.  i.  d.).  As  their  effect  is  very  uncertain,  it  is  wise  to  combine 
several  in  one  prescription — e.  g. : 

fy.  Strychnine  sulph.,  gr.  j  ; 

Aloes  Socotr.,  Bj ; 

Quininae  sulph.,  3ij ; 

Ferri  sulphat.  exsiccat.,  9ij  ; 

Ol.  sabinae,  3j ; 

Extr.  gentian,  co.,  q.  s. 

Ft.  pill.  No.  Ix. 

Sig.  Three  pills  three  times  a  day. 

It  is  also  well  to  combine  the  use  of  drugs  with  the  other  remedial 
agents  recommended. 


ABNORMAL  MENSTRUATION  AND  METRORRHAG1A.      241 

If  in  cases  of  rudimentary  uterus  the  development  is  so  insufficient 
that  there  is  no  hope  of  help  from  electricity  and  the  other  remedies, 
and  if  the  nervous  symptoms  are  very  distressing,  the  removal  of  the 
uterine  appendages  is  indicated.  If  the  apparent  ameuorrhea  is  in 
reality  retention  of  the  menstrual  blood  behind  an  obstruction  in  the 
genital  canal,  the  removal  of  the  obstruction  by  operations  that  will 
be  described  in  treating  of  the  diseases  of  the  special  organs,  is  the 
only  means  of  saving  the  patient's  life. 

Scanty  menstruation  is  a  lower  degree  of  ameuorrhea,  and  is  treated 
on  the  same  principles  especially  with  tonics  and  electricity. 


CHAPTER    II. 

VICARIOUS  MENSTRUATION. 

VICARIOUS  menstruation,  or  xenomenia,  consists  in  the  occurrence, 
at  the  time  of  menstruation,  of  bleeding  from  another  part  of  the 
body  than  the  uterus,  or  the  appearance  of  another  secretion.  The 
vicarious  bleeding  may  sometimes  take  place  alone,  instead  of  the  nor- 
mal uterine  monthly  discharge,  or  it  may  be  combined  with  it  so  as  to 
be  supplementary.  In  the  latter  case  the  flow  from  the  normal  source  is 
generally  scanty.  Vicarious  menstruation  has  been  found  to  appear  on 
nearly  every  mucous  membrane  and  every  part  of  the  skin,  the  most 
common  places  being  the  stomach,  the  breasts,  and  the  lungs.  As  to 
other  secretions,  serous  diarrhea  and  increase  of  leucorrheal  discharge 
have  been  observed  to  accompany  or  replace  menstruation.  I  have 
myself  seen  colostrum  in  the  breasts  and  profuse  perspiration  appear 
at  the  menopause.1 

Vicarious  menstruation  is  a  rather  rare  condition.  It  is  mostly 
found  in  weak,  nervous,  hysterical  women.  Wounds,  ulcers,  and 
varicose  veins  predispose  to  it. 

Symptoms. — Generally  the  patient  has  both  menstrual  molimen  in 
the  pelvis  and  congestion,  swelling,  and  pain  in  the  place  where  the 
vicarious  bleeding  is  to  occur. 

Prognosis. — The  importance  of  the  affection  depends  on  the  nature 
of  the  locality  affected.  A  bleeding  from  the  skin  or  the  nose  is  far 
less  serious  than  that  from  the  stomach  and  the  lungs.  In  general 
the  chances  of  stopping  the  abnormal  loss  of  blood  are  good  if  we 
succeed  in  bringing  back  or  increasing  the  normal  flow. 

Treatment. — The  treatment  is  chiefly  directed  to  the  relief  of  the 
amenorrhea  or  scanty  menstruation  (p.  240).  The  ectopic  bleeding 
calls  only  for  treatment  if  it  becomes  excessive,  and  is  then  treated 
according  to  the  general  rules  of  medical  and  surgical  practice. 

1  Garrigues,  Amer.  Jour.  Obst.,  1884,  vol.  xvii.  p.  524. 
16 


242  DISEASES  OF  WOMEN. 

CHAPTER    III. 

DYSMENORRHEA. 

DYSMEXORRHEA  is  the  condition  in  which  the  menstrual  process 
gives  rise  to  pain  in  the  pelvic  organs.  The  pain  may  precede  or 
accompany  the  flow.  It  may  be  due  to  diseases  of  the  ovaries,  the 
tubes,  the  uterus,  the  pelvic  peritoneum,  or  connective  tissue,  or  be  of 
purely  nervous  origin.  If  the  dysmenorrhea  is  due  to  inflammation 
of  the  uterine  appendages  and  the  contiguous  part  of  the  peritoneum 
and  connective  tissue,  i.t  appears,  as  a  rule,  earlier — as  much  as  eight 
days  before  the  flow  begins — and  a  relief  is  felt  when  the  congestion 
is  diminished  by  the  physiological  rupture  of  capillaries  taking  place 
in  the  mucous  membrane  (p.  117).  The  pain  is  situated  in  the  sides 
of  the  pelvis  or  the  iliac  fossa?.  Sometimes  it  seems  to  be  due  merely 
to  a  toughness  in  the  texture  of  the  ovary  which  interferes  with  the 
free  development  of  the  Graafian  follicle. 

If  the  dysmenorrhea  comes  from  the  uterus  itself,  it  may  be  due 
to  inflammation  of  the  mucous  membrane  or  the  muscular  tissue 
(endometritis  or  parenchymatous  metritis).  There  may  be  an  intra- 
uterine  polypus  playing  the  role  of  a  ball  valve,  or  the  simple  swell- 
ing of  the  mucous  membrane,  especially  at  the  internal  os,  may  pre- 
vent the  escape  of  the  blood  from  the  cavity,  or  the  uterus  may  be  so 
bent  that  the  crookedness  of  its  canal  opposes  a  barrier  to  the  free 
outflow  of  the  blood. 

It  is  especially  anteflexion  which  predisposes  to  dysmenorrhea,  but 
the  more  pronounced  cases  of  retroflexion  have  a  similar  effect.  The 
cervical  canal  may  be  too  narrow,  especially  at  the  internal  or  external 
os  (stenosis).  Sometimes  clots  are  formed  in  the  uterus,  the  expulsion 
of  which  causes  labor-like  pain  in  the  back  and  behind  the  symphysis. 
Sometimes  the  whole  mucous  membrane  is  thrown  off  and  expelled 
with  similar  pains — a  condition  called  membranous  dysmenorrhea. 

Uterine  dysmenorrhea  is  felt  more  centrally  and  appears  a  shorter 
time  before  the  appearance  of  the  flow,  and  continues  often  for  several 
days  after  it  has  begun. 

That  dysmenorrhea  which  is  due  to  closure  of  the  genital  canal 
and  retention  of  the  menstrual  blood  has  already  been  mentioned  in 
the  chapter  on  Amenorrhea  (p.  239). 

Nervous  dysmenorrhea  may  be  due  to  over-sensitiveness  of  the 
nerves,  so  that  the  normal  congestion  of  menstruation  is  perceived  as 
a  painful  pressure,  and  it  may  be  caused  by  muscular  contraction  of 
the  internal  os. 

The  degree  of  dysmenorrhea  varies  from  a  slight  discomfort  to  the 
most  excruciating  pain,  that  unfits  the  patient  for  any  work  and 
almost  makes  life  unendurable. 


ABNORMAL  MENSTRUATION  AND  METRORRHAGIA.      243 

Prognosis. — The  prognosis  varies,  especially  with  the  etiology.  In 
most  cases  we  may  promise  relief,  if  not  a  cure. 

Treatment. — The  treatment  varies  likewise  very  much  with  the 
causes.  In  young,  undeveloped  girls,  without  any  inflammatory 
complications,  we  try  to  avoid  a  vaginal  examination.  Even  a  rectal 
one  may  be  dispensed  with  for  some  time.  Tonics  (p.  226),  exercise 
in  open  air,  gymnastics  (p.  191),  general  massage  (p.  190),  towel-baths, 
shower-baths,  and  sea-bathing  (p.  188),  are  the  chief  remedies.  Where 
there  is  any  form  of  inflammation  exercise  can  only  be  taken  with 
great  caution  and  within  narrow  limits,  and  the  patient  ought  to  stay 
in  bed  during  the  attack.  The  treatment  of  the  special  diseases 
causing  dysmenorrhea  will  be  found  under  the  description  of  the  dis- 
eases of  the  different  organs,  but  for  convenience's  sake  we  will  briefly 
refer  to  it  here. 

In  all  inflammatory  conditions  we  use  hot  vaginal  injections  (p. 
171),  painting  of  the  vaginal  roof  with  tincture  of  iodine  (p.  170), 
pledgets  with  glycerin,  iodine-glycerin,  or  ichthyol-glycerin  (p.  178), 
faradization  with  the  secondary  current  (p.  229),  galvanism  or  scar- 
ification of  the  vaginal  portion  (p.  186).  In  endometritis  we  make 
applications  to  the  endometrium  (p.  170). 

In  anteflexion  the  regular  use  of  the  uterine  sound  gives  great 
relief.  A  retroflexed  womb  is  replaced  and  a  Hodge's  pessary  intro- 
duced into  the  vagina.  Outerbridge's  intra-uterine  drainage  pessary 
(p.  184)  may  prove  useful.  For  flexions  or  mere  stenosis  the  cervical 
canal  is  dilated  with  Hanks'  and  Garrigues'  dilators  (p.  155),  either 
moderately  (below  half  an  inch)  or  to  the  full  extent  of  the  latter 
instrument  (divulsion).  The  narrow  canal  may  also  be  gradually 
dilated  with  the  negative  pole  of  the  galvanic  battery.  In  cervical 
anteflexion  it  may  become  necessary  to  split  the.  posterior  lip  of  the 
cervix  (Sims's  operation).  In  desperate  cases  of  dysmenorrhea  due 
to  inflammation  of  the  ovaries  and  tubes  salpingo-oophorectomy  is 
the  last  resort. 

The  purely  nervous  dysmenorrhea  is  treated  with  tonics  and  seda- 
tives (p.  226). 

During  the  attack  all  forms  need  some  immediate  relief.  Since 
these  conditions  often  last  long  and  a  baneful  habit  might  be  acquired, 
we  should  be  careful  not  to  abuse  narcotics,  but  in  bad  cases  they  are 
unavoidable.  I  often  use  an  anti-dysmenorrheic  pill  of  the  following 
composition : 

1^.  Extr.  conii  ale.,  9j  ; 

Extr.  strammon.  ale., 

Extr.  opii,  da.  gr.  v. 

Ft.  pil.  No.  x. 
Sig.  One  pill  at  most  three  times  a  day. 

In  the  milder  cases  hot  dry  or  wet  fomentations  of  the  abdomen, 


244  DISEASES  OF  WOMEN. 

and  hot  drinks,  such  as  hot  tea  or  hot  brandy  and  water  or  an  infu- 
sion of  antherais  or  matricaria,  may  suffice.  Antipyrin  (gr.  x), 
antifebrin  (gr.  v),  and  phenacetin  (gr.  viiss)  should  all  be  tried  before 
narcotics  are  used  ;  and  they  have  often  splendid  effect.  If  necessary, 
a  second  dose  is  given  after  an  hour,  and  a  third  after  three  hours. 
Viburnum  prunifolium  is  also  a  uterine  sedative :  since  the  taste  and 
odor  of  the  fluid  extract  are  most  offensive  to  many  patients,  it  is 
well  to  give  it  inspissated  in  capsules  (dose  3j  of  the  fluid  extract, 
t.  i.  d.). 

Among  the  older  drugs  apiol  (a  capsule  with  TTLv  from  three  to  six 
times  a  day),  pulsatilla  (iTtij— iij  of  the  fluid  extract  in  water,  three  or 
four  times  a  day  during  the  week  preceding  menstruation),  and  can- 
nabis  Indica  (20  drops  of  the  tincture  every  three  hours  during  the 
pain),  are  yet  praised. 

There  is  a  widespread  popular  belief  that  marriage  is  a  panacea  for 
all  sufferings  in  a  girl,  but  nothing  could  be  more  erroneous.  If 
marital  relations  may  work  as  a  stimulus,  like  electricity,  to  imper- 
fectly developed  genitals,  calm  an  irritated  nervous  system,  effectually 
cure  a  stenosis  or  flexion,  by  the  occurrence  of  conception  and  child- 
birth, on  the  other  hand  inflammatory  conditions  of  the  pelvic  organs 
get  much  worse  by  the  congestion  produced  by  coition  and  the  stretch- 
ing of  all  the  organs  unavoidably  connected  with  pregnancy  and 
childbirth  (p.  129). 


CHAPTER   IV. 

PRECOCIOUS  AND  TARDY  MENSTRUATION. 

A  SINGLE  discharge  of  blood  from  the  genitals  is  sometimes  found 
in  little  children,  even  in  the  new-born,  without  any  apparent  disease. 
Irregular  bleeding  may  take  place  from  a  sarcoma.  But  we  can  only 
speak  of  precocious  menstruation  when  there  is  a  regular  return  of 
the  bleeding  from  the  genitals  every  four  weeks  in  children  below 
the  age  of  puberty.  This  is  a  very  rare  affection.  It  has  been 
observed  in  a  child  less  than  a  year  old,  and  several  cases  are  on 
record  dating  from  the  second  year.  As  a  rule,  both  the  external 
and  internal  genitals  and  the  breasts  are  abnormally  developed  in 
such  children,  and  sometimes  they  show  sexual  appetite.  Their  con- 
stitution suffers  under  the  untimely  loss  of  blood.  There  is  nothing 
to  be  done  for  them  except  to  try  to  combat  the  general  weakness, 
keep  them  quiet  at  the  time  of  menstruation,  and  watch  them  in 
regard  to  masturbation.  To  check  the  flow  might  lead  to  vicarious 
menstruation. 


ABNORMAL   MENSTRUATION  AND  METRORRHAGIA.       245 

Tardy  menstruation  is  the  first  appearance  of  the  menstrual  flow  at 
an  unusually  advanced  age.  It  has  been  seen  to  begin  as  late  as 
thirty-one  years.  This  condition  has  been  considered  under  the 
subject  of  Amenorrhea. 


CHAPTER  V. 

MENORRHAGIA. 

MENORRHAGIA  is  too  great  a  loss  of  blood  from  the  uterus  at  the 
time  menstruation  is  due.  The  increased  loss  may  either  be  due  to  a 
shortening  of  the  interraenstrual  period,  or  to  a  protracted  duration 
of  the  flow,  or,  most  of  all,  to  an  increase  of  the  amount  lost  at  each 
period.  Since  the  normal  amount  is  not  known,  and,  at  all  events, 
varies  much,  we  cannot  indicate  in  an  exact  \vay  where  meuorrhagia 
begins,  but,  practically,  we  call  the  flow  so  if  it  suddenly  becomes 
much  more  profuse  than  the  woman  usually  has  it,  and  if  it  weakens 
her. 

Etiology. — Menorrhagia  is  in  most  cases  due  to  a  disease  of  the 
uterus,  such  as  endometritis,  chronic  metritis,  subinvolution,  lacerated 
cervix,  a  granular  condition  of  the  os,  a  fibroid  tumor,  a  polypus,  or 
cancer.  It  may  also  be  due  to  the  different  kinds  of  displacements 
of  the  uterus.  Secondly,  it  may  be  due  to  ovarian  diseases,  especially 
oophoritis  and  small  ovarian  tumors.  Thirdly,  certain  general  acute 
infectious  diseases  are  apt  to  cause  profuse  menstruation,  especially 
cholera,  small-pox,  scarlet  fever,  typhoid  fever,  and  inflammatory 
rheumatism.  Among  the  chronic  diseases  hemophilia,  syphilis,  chlo- 
rosis, and  malaria  especially  give  rise  to  profuse  menstruation. 

Sometimes  the  cause  is  to  be  sought  in  diseases  of  the  heart,  the 
liver,  or  the  kidneys. 

Sometimes  no  cause  can  be  assigned — e.  g.  for  the  not  infrequent 
menorrhagia  found  in  young  girls  at  the  beginning  of  menstrual  life. 

Symptoms. — Besides  the  increased  loss  of  blood,  there  are  other 
symptoms  due  to  it.  If  the  loss  is  very  heavy,  it  may  cause  acute 
anemia  with  rapid,  flagging  pulse,  dyspnea,  pallor,  cold  clammy  skin, 
faintness,  or  syncope.  But  oftener  we  find  a  chronic  anemia  charac- 
terized by  pallor,  weakness,  asthenopia,  and  backache. 

Diagnosis. — The  diagnosis  between  menorrhagia  and  metrorrhay'm 
— i.  e.  uterine  hemorrhage  occurring  independently  of  menstruation 
— is  sometimes  difficult  or  impossible  when  so  frequent  hemorrhages 
take  place  that  the  patient  does  not  herself  know  what  would  be  the 
regular  time  for  a  menstrual  flow  to  come  on  ;  but  in  most  cases  the 
distinction  can  be  made  by  the  time  elapsed  since  the  last  bleeding, 
by  the  sensations  which  generally  precede  the  menstrual  flow,  by  the 


246  DISEASES  OF  WOMEN. 

admixture  of  mucus  with  the  blood,  and  by  the  gradual  way  in  which 
it  appears. 

Prognosis. — It  is  doubtful  if  ever  a  woman  has  died  directly  of 
menorrhagia,  but  repeated  losses  undermine  health  and  shorten  life. 

Treatment. — In  the  mildest  cases  we  prescribe  ergot  and  other 
internal  hemostatics  (p.  227),  rest,  cool  diet,  and  abstinence  from 
alcoholic  drinks  and  coffee.  The  bowels  should  be  kept  open  with 
saline  aperients  (p.  225).  If  there  is  any  excitement,  bromides 
and  opiates,  especially  opium  suppositories  (p.  226),  are  indicated. 
If  this  treatment  does  not  have  the  desired  effect,  vaginal  injec- 
tions with  hot  water  may  be  added.  If  they  do  not  check  the 
hemorrhage,  we  add  liq.  ferri  chloridi  to  the  water  (p.  182).  If  the 
bleeding  continues,  an  intra-uterine  injection  of  hot  water  with  or 
without  liq.  ferri  is  given  (p.  172).  A  bag  with  hot  water  applied  to 
the  lumbar  region  is  sometimes  effective.  An  ice-bag  is  placed  over 
the  symphysis  (p.  187).  If  all  this  is  ineffectual,  or  if  the  hemorrhage 
is  alarming,  we  tampon  the  vagina  (p.  179)  or  the  uterus  (p.  180). 

In  the  intermenstrual  period  a  treatment  is  instituted  according  to 
the  cause  of  the  menorrhagia.  If  the  endometrium  is  affected,  the 
uterus  is  treated  with  applications  of  liquor  ferri  (p.  170),  curetted 
(p.  176),  or  cauterized  by  means  of  chemical  galvano-cauterization 
(p.  233)  with  the  positive  pole  in  the  uterus.  Granulations  are  de- 
stroyed, the  torn  cervix  united,  a  polypus  removed,  and  a  fibroid 
treated  as  taught  under  the  discussion  of  that  disease.  Ovarian 
inflammation  is  treated  with  injections,  applications,  resolvents  (p. 
226),  glycerin  pledgets,  galvanism,  etc. 

At  the  same  time  we  try  by  means  of  hemostatics,  tonics,  and  food 
to  build  up  the  patient  as  much  as  possible  before  the  occurrence  of 
the  next  menstruation  (pp.  224-228). 

In  cases  of  heart  disease  a  moderate  bleeding  gives  relief,  and 
should,  therefore,  not  be  checked  too  soon.  Digitalis,  strophanthus,. 
and  aconite  are  valuable  remedies  under  such  circumstances.  When 
the  liver  is  torpid,  attention  to  diet,  abstention  from  alcoholic  drinks, 
and  the  administration  of  calomel,  pulv.  hydrargyri  cum  creta,  or 
euonymin  (gr.  ss-v)  are  indicated.  In  kidney  disease  especial  atten- 
tion should  be  paid  to  the  vicarious  functions  of  the  skin  and  bowels. 

The  physician  must  not  forget  that  a  moderate  loss  of  blood 
is  a  normal  condition,  a  kind  of  safety-valve,  for  the  female  economy. 
He  must,  therefore,  allow  a  reasonable  amount  of  blood  to  escape 
before  he  begins  to  check  the  flow.  As  a  rule,  I  let  patients  suffering 
from  menorrhagia  bleed  from  two  to  four  days  before  interfering,  but 
a  dangerous  loss  of  blood  should  be  stopped  at  any  time  by  the  most 
potent  measures.  How  to  act  in  a  given  case  can  only  be  learned  by 
tact  and  experience.  If  everything  else  fails  to  check  menorrhagia, 
Tait  recommends  the  removal  of  the  appendages. 


ABNORMAL  MENSTRUATION  AND  METRORRHAG1A.      247 

CHAPTER   VI. 

METEORRHAGIA. 

METRORRHAGIA  is  a  profuse  uterine  hemorrhage  occurring  at 
another  time  than  the  menstrual  flow.  Its  causes,  symptoms,  and 
treatment  are  essentially  the  same  as  those  of  menorrhagia,  just  de- 
scribed, with  the  exception  that  this  flow,  being  entirely  abnormal, 
need  not  be  allowed,  and  may,  therefore,  be  treated  more  actively  from 
the  very  beginning,  unless  the  bleeding  has  a  beneficial  influence  on 
some  diseased  condition — e.  g.  pelvic  inflammation. 


CHAPTER   VII. 

GENERAL  MENSTRUAL  DISORDERS. 

THE  menstrual  process  being  a  general  condition  of  which  the 
secretion  of  blood  from  the  mucous  membrane  of  the  uterus  is  only 
one  feature,  there  is  hardly  any  part  of  the  body  in  which  we  may 
not  find  more  or  less  important  disturbances  connected  with  it.  These 
occur  especially  before  the  flow  appears  or  in  the  beginning  of  the 
same.  They  may  accompany  a  normal  bloody  discharge  from  the 
genitals,  but  are  more  commonly  combined  with  amenorrhea  or  scanty 
menstruation. 

The  Nervous  System. — Headache,  especially  in  the  shape  of 
migraine,  is  quite  common.  Sometimes  neuralgic  pains  are  felt, 
especially  in  the  arms  and  legs.  Hysteria  may  be  entirely  due  to 
menstrual  disorders  or  get  worse  at  every  period.  In  exceptional 
cases  it  may  reach  the  highest  degree,  so-called  hystero-epilepsy. 
True  epilepsy  may  only  appear  at  the  time  of  impending  menstrua- 
tion, or  the  attacks  may  be  worse  every  time  the  period  recurs.  In 
insane  women  the  influence  of  menstruation  is  very  marked.  As  a 
rule,  maniacal  attacks  get  worse  or  appear  only  at  that  time.  Symp- 
toms of  impulsive  insanity,  such  as  kleptomania  or  the  impulse  to 
murder,  are  sometimes  decidedly  increased  by  menstruation.  The 
insanity  of  girls  at  puberty,  especially  that  pyromania  which  drives 
them  to  set  houses  or  hayricks  on  fire  irrespective  of  consequences, 
may  be  parallelized  with  that  of  the  menopause  which  we  have 
already  mentioned  (p.  124). 

The  Eyes. — Existing  inflammation  gets  very  frequently  worse.  In 
those  suffering  from  exophthalmic  goiter  the  eyes  are  more  prominent. 
The  condition  known  as  hysteric  copiopia l  acquires  generally  increased 

1  This  disease,  described  by  Foerster,  is  characterized  by  pain  in  the  region  of  the 


248  DISEASES  OF  WOMEN, 

intensity.  Blood  may  be  extravasated  into  the  anterior  camera  or 
behind  the  retina.  Papillary  inflammation,  optic  neuritis,  ueuro-reti- 
nitis,  and  complete  amaurosis  have  been  observed.  The  formation 
of  sties  is  very  common. 

The  Ear. — Vicarious  menstruation  may  occur  from  the  ear.  Exist- 
ing granulations  swell ;  purulent  discharge,  buzzing  sound,  and  deaf- 
ness increase  frequently. 

The  Nose. — Profuse  epistaxis  may  be  due  to  vicarious  menstruation. 

The  skin  is  often  the  seat  of  exanthemata,  such  as  acne,  urticaria, 
eczema,  exudative  erythema,  herpes,  etc.  The  latter  appears  not 
infrequently  on  the  genitals,  which  also  are  liable  to  become  the  prey 
of  pruritus.  The  legs  and  the  face  may  become  edematous.  Some- 
times there  is  free  perspiration,  with  or  without  an  unpleasant  smell, 
or  seborrhea  of  the  scalp.  Besides  vicarious  menstruation  in  the 
shape  of  blood  trickling  out  through  fissures  forming  in  the  skin, 
there  are  sometimes  minute  ecchymoses  in  the  same. 

The  Digestive  Tract. — Sometimes  the  tongue  is  coated  ;  the  patient 
suffers  from  toothache,  aphthous  stomatitis,  or  sore  throat.  As  men- 
tioned above,  the  stomach  may  be  the  seat  of  vicarious  menstruation, 
from  a  few  teaspoonfuls  to  over  two  pounds  of  blood  being  vomited. 
There  may  also  be  a  hemorrhoidal  flow  or  diarrhea.  In  rarer  cases  a 
dull  pain  in  the  right  hypochoudrium  betokens  a  congestion  of  the 
liver,  which  may  even  lead  to  jaundice. 

The  Respiratory  System. — The  thyroid  body  swells  not  infre- 
quently, especially  in  those  afflicted  with  goiter,  and  this  swelling 
may  cause  such  a  compression  of  the  trachea  that  tracheotomy  be- 
comes necessary.  We  have  mentioned  above  that  the  lungs  are  one 
of  the  seats  of  predilection  for  vicarious  menstruation.  This  hemor- 
rhage may  be  dangerous  in  itself,  and  may  be  a  precursor  of  phthisis. 

The  circulatory  system  does  not  suffer  much,  except  that  palpitations 
are  not  uncommon,  and  that  angiomas  and  varicose  veins  are  liable  to 
increase. 

The  Urinary  Organs. — The  sufferings  due  to  floating  kidney  be- 
come worse  during  the  congestion  preceding  menstruation.  There  is 
a  frequent  desire  of  evacuating  the  urine,  and  the  bladder  may  be  the 
seat  of  vicarious  menstruation. 

conjunctiva!  fold,  in  or  behind  the  eye,  the  forehead,  less  frequently  in  the  malar 
bones  or  the  superior  maxilla,  and  by  a  peculiar  kind  of  photophobia  experienced 
in  regard  to  artificial  light  in  a  dark  room,  besides  a  great  variety  of  hyperesthetic 
phenomena.  It  attacks  both  eyes.  It  is  incurable,  but  disappears  spontaneously, 
often  after  many  years.  It  is  frequent  in  the  higher  classes,  and  is  by  far  more 
common  in  women  than  in  men.  It  is  said  in  the  former  to  be  a  reflex  neurosis 
from  chronic  parametritis.  As  treatment  it  is  recommended  to  let  the  patient  take 
£  drachm  of  Canadian  castoreum  and  1  drachm  of  extract  of  valerian  in  the 
course  of  four  days,  which  gives  relief  for  several  weeks.  At  the  same  time  the 
patient  should  use  eye-drops  with  acetate  of  zinc  (W.  A.  Freund,  Gyndkologische 
Klinik,  Strasburg,  1885,  vol.  i.  pp.  265-272). 


ABNORMAL  MENSTRUATION  AND  METRORRHAGIA.      249 

The  Genitals. — Displaced  ovaries  may  become  particularly  painful, 
and  the  swelling  of  the  ovary  enclosed  in  a  hernia  may  give  rise  to 
strangulation.  Fibroids  often  grow  larger,  and  intra-uterine  polypi 
may  be  pushed  down  into  the  cervix  or  the  vagina.  In  cases  of 
atresia  we  have  seen  that  the  pain  increases  at  each  new  outpouring 
of  blood  that  finds  no  vent.  Leucorrhea  precedes  or  follows  very 
frequently  the  menstrual  flow,  or  appears,  as  stated  above,  as  a  sub- 
stitute for  it. 

The  breasts  not  uncommonly  become  swollen  and  painful,  and 
they  are  one  of  the  more  frequent  seats  of  vicarious  menstruation. 

Patients  affected  with  divers  chronic  diseases  often  feel  more  dis- 
comfort during  menstruation.  It  is  claimed  that  amenorrhea,  with- 
out the  presence  of  any  other  disease,  may  cause  edema  and  ascites, 
and  that  menstruation  has  a  very  bad  effect  on  the  progress  of  osteo- 
malacia. 

Treatment, — In  all  affections  connected  with  ameuorrhea  or  scanty 
menstruation  the  first  indication  is  to  try  to  bring  on  or  increase  the 
menstrual  flow,  except  in  those  cases  in  which  there  is  a  general 
debility  that,  presumably,  would  be  made  worse  by  any  loss  of  blood. 
Under  these  latter  circumstances  the  first  thing  to  do  is  to  strengthen 
the  general  health.  Secondly,  the  different  special  disturbances  call 
for  treatment.  Headache  and  neuralgia  are  often  relieved  by  the 
administration  of  phenacetin,  antipyrin,  antifebrin,  caffeine  (gr.  j  to  iij 
t.  i.  rf.),  or  the  combination  called  effervescent  granulated  bromo-caf- 
feine  (a  heaping  teaspoonful),  pulv.  paulliniee  (gr.  xx,  L  i.  d.\  extr. 
cannabis  (gr.  J  to  ^,  or  20  to  40  minims  of  the  tincture,  t.  i.  <£).  A 
favorite  combination  of  mine  is — 

1^!.  Phenacetini,  3j ; 

Caffeina?,  gr.  xxiv ; 

Sodii  bromidi,  sij. 

M. — Div.  in  ptt.  aequ.  No.  xii.     Det.  ad  chart,  cerat. 
Sig.  1  powder  repeated,  if  needed,  after  1  and  3  hours. 

In  regard  to  the  treatment  of  the  manifold  other  disturbances  men- 
tioned above  we  must  refer  the  reader  to  works  on  the  practice  of 
medicine,  special  treatises,  and  later  chapters  of  this  Manual.1 

1  Those  familiar  with  German  may  find  much  valuable  information  in  Leopold 
Meyer's  Der  Menstruation sprozess  und  seine  Krankhaften  Abweichungen,  Stuttgart,  1890. 


PART  VIII. 

LEUCORRHEA. 

NORMALLY,  the  genital  tract  is  just  moist  enough  to  be  soft  and 
slippery ;  nowhere  a  drop  of  fluid  is  visible.  Any  mucous,  serous,  or 
purulent  discharge  is  abnormal,  and  constitutes  in  itself  a  disease  or 
is  a  symptom  of  one. 

The  word  "  leucorrhea  "  means  a  white  flow,  but  it  is  used  to  des- 
ignate any  discharge  other  than  blood  coming  from  the  genitals. 
Popularly  the  disorder  is  called  "  the  whites." 

The  discharge  may  come  from  the  vulva,  the  vagina,  the  neck  or 
the  body  of  the  womb.  That  from  the  vulva  and  the  vagina  is  acid, 
that  from  the  uterus  alkaline.  The  microscope  reveals  flat  epithelial 
cells  in  vulvar  and  vaginal  leucorrhea,  an  abundance  of  mucous  cor- 
puscles in  the  cervical,  and  columnar  epithelial  cells,  sometimes  cili- 
ated, in  that  coming  from  the  uterus,  be  it  from  the  neck  or  the  body 
(p.  51).  The  fluid  is  serous,  mucous,  or  purulent,  and  may  have  an 
admixture  of  a  little  blood.  It  may  be  colorless,  white,  yellow,  green, 
red,  or  brown.  The  white  color  is  due  to  the  presence  of  epithelial 
cells,  the  yellow  to  pus,  the  red  to  fresh  blood,  and  the  brown  to 
decomposed  blood.  It  may  be  nearly  as  thin  as  water  or  more  or 
less  thick  like  cream  and  soft  cheese.  A  colorless,  thick  fluid  like 
the  raw  white  of  an  egg  is  exclusively  secreted  by  the  goblet-shaped 
cells  found  in  the  depressions  between  the  branches  of  the  arbor 
vitae  (p.  51). 

Leucorrnea  is  idiopathic,  specific,  or  symptomatic.  A  leucorrhea  is 
called  idiopathic  when  it  is  not  due  to  any  permanent  structural  ana- 
tomical lesion.  It  is  then  constitutional  and  forms  a  disease  in  itself. 

The  specific  leucorrhea  is  that  due  to  gonorrheic  infection. 

A  leucorrhea  is  symptomatic  when  it  is  one  symptom  among  others 
of  a  certain  disease. 

Causes. — 1.  Idiopathic  Leucorrhea.1 — Like  other  catarrhal  affec- 
tions, and  often  combined  with  them,  it  may  be  due  to  a  cold,  damp 
climate  or  residence.  It  may  be  connected  with  plethora  or  anemia. 
It  may  be  induced  by  anything  that  weakens  the  constitution,  such 
as  protracted  lactation,  bodily  or  mental  fatigue,  emotions,  especially 
of  a  depressing  kind,  and  insufficient  nourishment.  It  occurs  fre- 
quently in  persons  predisposed  to  pulmonary  phthisis.  It  is  some- 

1  Fordyce  Barker's  paper,  "  Leucorrhea  considered  in  Relation  to  its  Constitutional 
Causes  and  Treatment,"   Trans.  Amer.  Gyn.  Soc.,  1882,  vii.  pp.  130-141,  contains 
many  valuable  hints  on  this  topic  that  has  disappeared  from  many  modern  treatises 
on  gynecology. 
250 


LEUCORRHEA.  251 

times  brought  on  by  local  irritation,  such  as  masturbation,  frequent 
coition,  gravidity,  childbirth,  or  abortion  ;  or  it  appears  in  consequence 
of  amenorrhea  or  scanty  menstruation  as  a  supplementary  or  vicarious 
menstruation,  not  only  during  the  period  of  menstrual  life,  but  fre- 
quently after  the  climacteric  has  been  established.  In  this  way  it 
may  also  take  the  place  of  lactation,  suppressed  perspiration,  hernor- 
rhoidal  flow,  diarrhea,  and  other  discharges. 

2.  The  specific  leucorrhea  due  to  gonorrheic  infection  will  be  con- 
sidered under  Vaginitis. 

3.  Symptomatic  Leucorrhea. — It  may  be  a  symptom  of  rheuma- 
tism, scrofulosis,  tuberculosis,  malaria ;  of  numerous  local  diseases  of 
the  genitals,  such  as  vulvitis,  colpitis,  endometritis,  metritis,  subinvo- 
lution,  granulations  at  the  os  or  in  the  interior  of  the  womb,  ulcers, 
a  lacerated  cervix,  polypi,  fibroids,  sarcoma,  carcinoma ;  or  of  diseases 
in  other  organs  which  interfere  with  a  free  circulation  in  the  genitals, 
such  as  disease  of  the  heart  and  the  liver. 

Symptoms. — The  leucorrheic  discharge  is  a  drain  on  the  system, 
which  has  given  rise  to  the  popular  belief  that  the  white  stuff  coming 
out  of  the  genitals  is  the  spinal  marrow  that  melts.  While  it  may 
be  brought  on  by  anemia,  it  may  also  lead  to  it.  The  patients  com- 
plain of  weakness,  backache,  neuralgia  in  different  parts  of  the  body, 
and  often  an  irritable  bladder.  Commonly  they  suffer  from  anorexia 
and  dyspepsia.  Frequently  there  are  menstrual  disturbances,  espe- 
cially too  frequeat,  too  long,  and  too  copious  menstruation,  or,  on  the 
other  hand,  amenorrhea.  Local  changes  in  the  cervix  and  the  vagina, 
especially  excoriations,  ulcerations,  granulations,  and  eversion  of  the 
mucous  membrane,  may  be  due  to  the  irritation  caused  by  the  dis- 
charge, just  as  we  find  vegetations,  eczema,  erythema,  intertrigo  spring- 
ing up  in  the  groins,  at  the  vulva,  and  on  the  inside  of  the  thighs. 

Prognosis. — Since  leucorrhea  is  found  under  such  extremely  different 
conditions,  nothing  can  be  said  in  a  general  way  about  the  prognosis. 
It  depends  mostly  on  the  cause. 

Treatment. — The  same  applies  to  the  treatment,  but  here  we  may 
add  that,  as  a  rule,  a  general  and  a  local  treatment  should  go  hand  in 
hand.  The  more  the  condition  depends  on  constitutional  causes,  the 
more  general  treatment  is  needed,  and  the  more  powerful  it  is ;  the 
more  local  disease  predominates,  the  more  actively  must  the  leucor- 
rhea be  combated  in  its  seat. 

The  most  substantial  food  and  invigorating  drinks  that  the  stomach 
can  digest  must  be  given  (p.  224),  and  digestion  is  to  be  helped  arti- 
ficially if  necessary.  The  patient  must  have  a  passage  once  in  twenty- 
four  hours.  She  must  wear  sufficiently  warm  clothes,  especially 
woolen  underwear  (pp.  128  and  168).  Tonic  medicines  (p.  226),  general 
massage  (p.  190),  gymnastics  (p.  191),  and  exercise  in  the  open  air, 
are  useful.  Change  of  climate,  locality,  and  surroundings  is  a  great 


252  DISEASES  OF  WOMEN. 

help.  The  patient  should,  if  possible,  be  sent  to  a  warm  dry  climate 
or  high  up  in  the  mountains,  but  at  the  same  time  pleasant  company 
should  be  provided.  A  cold  and  damp  dwelling  must  be  exchanged 
for  a  dry  and  sunny  one.  Different  kinds  of  baths  (p.  187)  are  to 
be  recommended :  warm  hip-baths,  tepid  general  baths,  Turkish  or 
Russian  baths,  are  especially  indicated  where  there  is  a  rheumatic 
diathesis.  Otherwise,  it  is  better  to  strengthen  the  nerves  and  harden 
the  skin  by  means  of  towel-,  sheet-,  or  sponge-baths,  shower-baths, 
hydrotherapy,  or  sea-baths.  In  many  cases  of  idiopathic  leucorrhea 
a  treatment  carried  out  on  these  lines  will  suffice  to  effect  a  cure. 
This  ought  especially  to  be  tried  in  intact  girls,  so  that  even  a  physical 
examination  may  be  avoided. 

In  most  cases,  however,  recourse  to  local  treatment  is  an  imperative 
addition  to  the  general  treatment.  Applications  of  tincture  of  iodine, 
solution  of  nitrate  of  silver,  carbolic  acid,  chloride  of  iron,  chloride 
of  zinc  (20  to  50  per  cent.),  etc.  are  made  to  the  affected  parts  (p.  170). 
If  there  is  no  free  drainage  from  the  uterus,  the  cervical  canal  should 
be  dilated  (p.  155).  Vaginal  injections  with  hot  water  or  astringents 
are  beneficial  in  most  cases'  (p.  170).  It  may  become  necessary  to 
remove  granulations  from  the  cervix  or  fungoid  growths  from  the 
inside  of  the  corpus  and  fundus,  or  to  scrape  the  endometrium  with 
the  curette  (p.  154),  or  to  burn  the  cervical  canal  with  the  thermo- 
cautery  (p.  182)  or  by  means  of  thermic  or  chemical  galvano-cauteri- 
zation  (pp.  235  and  231).  The  mucous  membrane  of  the  cervix  may 
also  be  cut  away. 

As  to  the  special  indications  to  be  met  in  regard  to  underlying 
general  or  local  diseases,  the  reader  is  referred  to  works  on  the  prac- 
tice of  medicine  and  to  later  chapters  of  this  manual. 

Some  internal  remedies,  such  as  aletris  (cordial,  5j  t.  i.  d.\  hydras- 
tis  (fluid  extract,  gtt.  xx,  t.  i.  rf.),  cimicifuga  (fluid  extract,  3ss  to  3j), 
inula  (a  decoction  of  the  root,  siij  to  water  q.  s.  ad  §iv,  to  be  taken 
every  morning),  seem  to  have  the  special  virtue  of  checking  leucorrhea. 

In  phthisical  patients  the  leucorrheal  flow  is  by  some  regarded  as 
a  kind  of  issue,  to  dry  up  which  would  precipitate  the  destruction 
of  the  lung.  The  local  treatment  should,  indeed,  be  of  the  mildest  or 
may  be  dispensed  with  altogether,  but  all  the  internal  remedies  rec- 
ommended, such  as  cod-liver  oil,  terraline,  hydroleine,1  etc.,  only 
strengthen  the  whole  constitution,  and  thus  benefit  the  lungs  indi- 
rectly, and  the  leucorrhea,  if  abundant,  being  in  itself  a  drain  on  the 
physical  strength,  can  hardly  fail  to  have  a  bad  influence  on  the 
pulmonary  affection. 

1  Terraline  is  a  product  gained  from  petroleum.  Hydroleine  is  a  mixture  of 
cod-liver  oil,  boracic  acid,  and  other  substances.  Both  of  these  medicines  have 
seemed  to  me  to  have  so  decided  an  effect  in  wasting  diseases  that  I  do  not  hesitate 
to  mention  them  here. 


DISEA.SES   OF  WOMEN. 


II. 

SPECIAL  DIVISION. 


SPECIAL  DIVISION. 


PART  I. 

DISEASES  OF  THE  VULVA. 


CHAPTER  I. 

MALFOKMATIONS.1 

1.  Absence  of  Vulva. — By  an  arrest  of  development  in  the  first 
month  of  fetal  life  the  external  genitals  and  the  anus  may  be  absent, 
the  skin  covering  the  region  uninterruptedly.     (See  p.  32.)     This 
condition  is  almost  always  combined  with  arrest  of  development  in 
other  organs,  and  is  only  found  in  non-viable  fetuses. 

If  the  anus  is  formed,  life  may  be  continued  without  external  geni- 
tals, the  urine  being  evacuated  through  the  navel.  Such  a  case  is 
on  record,  and  was  cured  by  the  formation  of  an  artificial  urethra 
and  closure  of  the  opening  of  the  urachus  at  the  umbilicus. 

2.  Hypospadias. — In  consequence  of  an  insufficient  closure  in  the 
median  line  the  lower  wall  of  the  urethra  may  be  split  more  or  less 
deeply  (Fig.  199).     If  the  defect  extends  very  deeply,  so  as  to  divide 
the  different  sphincters  of  the  urethra  (p.  76),  the  patient  cannot 
retain  her  urine.     A  small  degree  of  hypospadias  is,  by  far,  not  so 
important  in  woman  as  in  man,  and  will  hardly  call  for  treatment. 
The  complete  congenital  hypospadias  has  been  successfully  treated  by 
paring  and  uniting  the  surrounding  mucous  membrane  to  such  an 
extent  as  to  form  an  artificial  urethra,  the  relations  of  which  to  the 
bladder  were  much  like  those  of  a  spout  to  a  teapot.2 

1  In  this  chapter  I  have  to  some  extent  used  my  article  on  this  subject  in  Ameri- 
can System  of  Gynecology,  edited  by  Mann,  Philadelphia,  1887,  vol.  i.  pp.  235-282. 

2  For  details  the  reader  is  referred  to  T.  A.  Emmet's  Gynecology,  2d  ed.,  pp.  649-654. 


256 


DISEASES  OF  WOMEN. 


3.  Epispadias. — Epispadias  (Fig.  200)  is  the  name  for  the  condi- 
tion characterized  by  a  lack  of  union  of  the  upper  wall  of  the  urethra. 
It  is  generally  combined  with  a  similar  defect  in  the  anterior  wall  of 
the  bladder  (extroversion).  The  clitoris  and  the  symphysis  pubis 
may  be  cleft  or  not.  These  defects  are  due  to  the  intracorporeal  part 


FIG.  199. 


Hypospadias  (Mosengeil) :  a,  open  canal,  formed  by  the  anterior  wall  of  the  urethra;  b,  pos- 
terior, closed  part  of  the  urethra :  c,  entrance  to  vagina ;  d,  hymen. 

of  the  allantois  being  pulled  abnormally  forward,  becoming  over- 
filled, and  finally  bursting. 

Epispadias,  like  hypospadias,  has  been  cured  by  different  plastic 
operations.  One  way  is  to  form  a  transverse  flap  of  the  mucous 
membrane  of  the  vestibule  and  stitch  it  to  the  meatus.  Another  is 
to  denude  two  lateral  surfaces  and  unite  them  in  front  of  the  open 
urethra. 

4.  Abnormalities  of  the  Clitoris. — Sometimes  the  clitoris  is  split  in 
two  lateral  halves,  without  any  cleavage  of  the  urethra  or  bladder, 
but  in  connection  with  a  non-united  symphysis  and  an  opening  in 
the  abdominal  wall  above  the  bladder.  Such  cases  are  exceedingly 
rare.  The  cleavage  of  the  clitoris  is  of  no  importance.  The  defect 
in  the  abdominal  wall  may  be  closed  according  to  the  general  rules 
of  plastic  surgery. 

The  clitoris  may  be  absent  or  very  small,  or,  on  the  other  hand,  as 
large  as  a  medium-sized  penis. 

This  hypertrophy  of  the  clitoris  may  be  inconvenient,  and  can  then 


DISEASES  OF  THE   VULVA. 


257 


be  remedied  by  amputation  with  the  galvano-caustic  wire  (p.  235), 
with  the  e'craseur,  or  with  Paquelin's  thermo-cautery  (p.  282). 

The  prepuce  is  very  frequently  adherent  to  the  glans,  and  in  many 
cases  this  condition  gives  rise  to  reflex  neuroses,  even  epilepsy  and 
nymphomania. 

Treatment. — The  vulva  should  be  washed  with  bichloride-of-mer- 
cury  solution.  A  couple  of  drops  of  cocaine  solution  are  thrown 


Epispadias  (Kleinwacbter) :  q,  fissure  in  the  bladder;  b,  labium  majus;  c,  clitoris ;  d,  labi 
minus ;  e,  hymen  ;  /,  vaginal  entrance. 


into  the  glans  clitoridis  with  a  hypodermic  syringe,  and  four  or  five 
drops  more  are  thrown  into  the  prepuce.  If  one  margin  of  the  pre- 
puce is  then  seized  with  a  fixation-forceps,  the  thumb-nail  will  easily 
complete  the  work  of  clearing  the  glans.  Raw  surfaces  are  sprinkled 
with  aristol  and  the  prepuce  packed  with  a  little  ball  of  corrosive- 
sublimate  gauze.  As  there  is  a  marked  tendency  to  recurrence  of  the 
17 


258  DISEASES  OF  WOMEN. 

adhesions,  and  the  consequent  nervous  reflexes,  this  packing  must  be 
repeated  every  two  or  three  days  until  the  appearance  of  normal 
smegma  shows  that  the  mucous  surfaces  have  developed  sufficiently 
to  take  care  of  themselves.1 

5.  Abnormalities  of  the  Labia  Minora. — The  labia  minora  may 
be  absent.     They  may  be  multiple,  each  being  split  lengthwise  in 
two  or  three  flaps.     They  are  sometimes  too  long,  which  is  found 
physiologically  in  whole  tribes.     (See,  for  instance,  Hottentot  apron, 
p.  37). 

This  condition  may  interfere  with  coition,  and  may  then  be  reme- 
died by  cutting  away  the  superfluous  tissue  and  uniting  the  edges  of 
the  wound,  which  will  heal  by  first  intention. 

6.  Abnormalities  of  the  Labia  Majora. — These  may  likewise  be 
split  by  longitudinal  clefts,  so  as  to  become  double  or  triple. 

Alone  or  together  with  the  labia  minora  they  may  extend  so  far 
back  as  to  reach  behind  the  anus,  so  that  there  is  no  perineum. 

7.  Epithelial  Coalescence. — During  the  second  half  of  fetal  devel- 
opment the  large  and  small  labia  may  grow  superficially  together 
from  behind  forward.     It  is  rare  that  the  coalescence  goes  so  far  as  to 
prevent  micturition  in  the  new-born  child.     Sometimes  it  may,  how- 
ever, give  an  inconvenient  direction  to  the  jet  of  urine.     Menstrua- 
tion may  become  difficult,  and  the  small  dimensions  of  the  vulvar 
opening  may  oppose  a  serious  obstacle  to  coition  or  childbirth. 

If  the  coalescence  is  combined  with  hypertrophy  of  the  clitoris,  the 
sex  may  become  doubtful. 

Treatment. — The  parts  ought  to  be  cut  open  in  the  median  line  on 
a  director  introduced  through  the  existing  opening,  and  kept  sepa- 
rated during  the  healing  process,  or,  if  the  cut  surface  is  large,  the 
edges  of  each  side  may  be  brought  separately  together  by  stitches. 

It  is  not  rare  that  the  urethra  alone  is  agglutinated,  so  that  the 
child  cannot  pass  its  urine.  All  that  is  needed  in  such  cases  is  to 
introduce  a  silver  probe  into  the  bladder.  Once  opened,  the  canal 
stays  open. 

8.  Hermaphrodism. — Hermaphrodism,  or  hermaphroditism,  is  the 
condition  in  which  the  characteristics  of  the  two  sexes  become  more 
or  less  blended  in  one  individual. 

From  the  history  of  the  development  of  the  genitals  we  know 
that  they  are  composed  of  three  parts,  each  of  which  has  its  inde- 
pendent embryonal  foundation — namely,  the  sexual  glands,  the  two 
sets  of  ducts  (Wolffian  and  Mullerian),  and,  finally,  the  external 
genitals  (pp.  20,  22,  30,  and  33).  It  is,  therefore,  not  so  difficult  to 
understand  how  one  of  these  parts  may  be  developed  according  to  a 
sexual  type  differing  from  that  of  the  others. 

1  Robert  T.  Morris  of  New  York,  Trans.  Amer.  Obstetricians  and  Gynecologists, 
1892. 


DISEASES  OF  THE   VULVA.  259 

It  is  more  difficult  to  understand  how  there  can  be  more  than  one 
set  of  reproductive  glands,  for  we  have  seen  (p.  22)  that  it  is  one 
and  the  same  body  that,  identical  in*  the  beginning,  later  becomes 
either  an  ovary  or  a  testicle.  But  while  the  connective-tissue  part  is 
identical  in  the  two  kinds  of  glands,  ovary  and  testicle,  it  is  not 
unlikely  that  the  epithelial  part  of  them  has  a  different  origin  in  the 
two  sexes.  Some  anatomists  claim,  indeed,  that  the  seminal  canals  in 
the  testicle  are  formed  as  invaginations  from  the  Wolffian  duct,  while 
we  know  that  the  follicles  in  the  ovaries  are  derived  from  the  germ- 
epithelium  (p.  28). 

We  know,  furthermore,  that  we  may  have  supernumerary  ovaries 
(p.  120),  and  the  same  is  claimed  in  regard  to  testicles,  although  it  is 
infinitely  rarer  with  them  than  with  ovaries. 

Hermaphrodism  is  true  or  spurious.  True  hermaphrodism  is  that 
in  which  at  least  one  ovary  and  one  testicle  are  found  in  the  same 
person.  There  may  be  found  a  complete  double  set  of  sexual  glands — 
*".  e.  two  ovaries  and  two  testicles  (true  bilateral  hermaphrodism) ;  or 
there  might  be  found  one  sexual  gland  on  one  side,  be  it  a  testicle  or 
an  ovary,  and  on  the  other  both  a  testicle  and  an  ovary  (true  unilateral 
hermaphrodism),  but  it  is  somewhat  doubtful  if  such  a  case  actually 
has  been  observed  or  not ;  or,  finally,  there  may  be  one  ovary  on  one 
side  and  one  testicle  on  the  other  (true  latei'al  hermaphrodism). 

True  hermaphrodism  is  at  best  exceedingly  rare,  and  its  existence 
is  not  even  universally  admitted. 

Spurious  hermaphrodism,  or  pseudo-hermaphrodiwi,  is  that  condi- 
tion in  which  the  sexual  glands  belong  to  one  sex,  either  masculine 
or  feminine,  and  the  passages  leading  from  them,  as  well  as  the  exter- 
nal parts,  approach  more  or  less  the  other.  Spurious  hermaphrodism 
is  subdivided  into  male  or  female  according  to  the  nature  of  the  sexual 
gland.  Each  of  these  classes  comprises  three  groups :  the  first  is 
formed  by  those  cases  in  which  the  ducts  alone  belong  to  the  oppo- 
site sex  (internal  male  or  female  pseudo-hermaphrodism) ;  the  second, 
by  those  in  which  the  external  parts  alone  represent  the  opposite  sex 
{external  male  or  female  pseudo-hermaphrodism) ;  and  the  third,  those 
in  which  both  the  ducts  and  the  external  parts  approach  the  type  of 
the  other  sex  (internal  and  external — or  complete — male  or  female 
pseudo-hermaphrodism). 

Pseudo-hermaphrodism,  as  well  as  true  hermaphrodism,  is  a  mal- 
formation that  dates  from  the  earliest  periods  of  fetal  development. 
It  is  much  more  frequently  found  in  the  male  than  in  the  female  sex, 
and  reaches  also  a  much  higher  degree  in  the  former,  so  that  a  vagina, 
uterus,  and  tubes  may  be  found  more  or  less  developed  in  an  indi- 
vidual with  testicles,  vasa  deferentia,  seminal  vesicles,  and  male 
external  genitals.  The  presence  of  menstruation  does  not  settle  the 
sex,  since  a  periodical  bloody  discharge  has  even  been  observed  to 


260  DISEASES  OF  WOMEN. 

take  place  from  normal  male  genitals,  and  especially  in  males  suffering 
from  hypospadias. 

The  external  genitals  being  formed  in  both  sexes  of  the  same  sub- 
stance, it  is  impossible  to  have  a  double  set  of  them,  one  male,  the 
other  female,  but  some  portions  may  assume  more  the  male,  others 
more  the  female,  type. 

The  general  appearance  of  the  body,  especially  in  regard  to  the 
length  of  the  hair,  the  development  of  the  breasts,  the  prominence 
of  Adam's  apple,  the  breadth  of  the  hips,  and  the  angularity  or 
rotundity  of  the  form,  presents  a  mixture  of  both  sexes,  the  prepon- 
derance being,  not  with  the  real  sex,  as  determined  by  the  sexual 
glands,  but  with  the  external  genitals. 

The  diagnosis  of  the  sex  of  hermaphrodites  is  often  difficult,  some- 
times impossible,  in  the  living  individual ;  nay,  even  the  pathological 
specimens,  when  examined  after  death,  present  so  many  deviations 
from  the  normal  conditions  that  they  are  interpreted  in  a  different 
manner  by  different  observers  of  equal  ability. 

When  there  is  any  doubt  about  the  sex  of  an  individual,  it  ought 
always  to  be  declared  a  male.  This  will  not  only  give  it  better 
chances  to  make  a  living  and  certain  privileges  in  regard  to  political 
and  hereditary  rights,  but  it  is  also  much  safer  to  bring  it  up  as  a 
boy.  A  "  girl  "  with  a  testicle  can,  if  the  sexual  appetite  awakens, 
do  much  harm  in  a  boarding-school,  and  if  it  does  not  awaken  she 
may  many  without  knowing  that  she,  from  a  physical  standpoint,  is 
an  unsatisfactory  mate. 


CHAPTER   II. 

RUPTURES  (HERNLE). 

Two  kinds  of  hernise  find  their  way  into  the  labia  majora — viz. 
the  anterior,  or  inguino-labial,  hernia  and  the  posterior,  or  vagino- 
labial,  hernia. 

1.  The  anterior  labial,  or  inguino-labial,  hernia  in  women  corre- 
sponds with  the  inguinal  hernia  in  men,  and  is  not  very  rare.  It 
comes  out  through  the  inguinal  canal,  follows  the  round  ligament, 
and  descends  into  the  anterior  part  of  the  labium  majus.  It  may  be 
found  on  both  sides  simultaneously  (double  inguinal  hernia).  At 
first  it  forms  a  round  tumor  in  the  region  of  the  external  abdominal 
ring;  later,  when  descending  toward  and  into  the  labium  majus,  it 
becomes  pear-shaped.  It  may  contain  the  gut,  the  omen  turn,  the 
ovary,  and  the  uterus,  and  when  impregnation  takes  place  even  a 
fetus  in  the  uterus. 

Diagnosis. — When  near  the  external  inguinal  ring,  it  may  be  mis- 


DISEASES  OF  THE   VULVA.  261 

taken  for  a  tumor  of  the  round  ligament,  or  kydrocele.  In  the 
labiuni  it  may  be  mistaken  for  an  abscess,  cyst,  or  tumoi\  As  a  rule, 
it  will  be  possible  to  make  the  distinction  by  paying  attention  to  the 
history,  by  a  resonant  percussion-sound,  by  the  increase  in  size  caused 
by  coughing  and  abdominal  pressure,  by  the  possibility  of  bringing 
it  back  into  the  abdominal  cavity  through  the  inguinal  canal,  by  the 
peculiar  sensation  of  the  gut  slipping  away  under  the  fingers,  by  a 
gurgling  sound  heard  during  taxis,  by  the  absence  of  local  inflamma- 
tion, and  by  the  absence  of  fluid,  or  by  the  nature  of  the  fluid  when 
aspiration  is  made  with  a  hypodermic  syringe. 

Treatment. — The  treatment  is  like  that  in  the  male — as  a  rule,  by 
means  of  a  truss,  sometimes  by  the  radical  operation.  When  it  is 
strangulated  and  cannot  be  reduced,  heruiotomy  is  imperative.  It 
may  become  necessary  to  extirpate  an  ovary  found  in  the  sac  and  to 
perform  Cesarean  section,  or,  preferably,  Porro's  operation  when 
pregnancy  occurs  in  the  imprisoned  uterus. 

A  variety  of  inguinal  hernia  found  in  little  girls  is  the  hernia  in 
the  canal  of  Nuck,  corresponding  with  the  hernia  of  the  tunica  vagi- 
nalis  in  the  male.  It  is  extremely  rare.  The  treatment  is  the  same. 

2.  Posterior  Labial,  or  Vagino-labial,  Hernia. — This  form  is  much 
rarer  than  the  preceding.  The  escaping  abdominal  viscera  here 
descend  in  front  of  the  uterus,  along  the  vagina  and  bladder,  between 
them  and  the  levator  ani  muscle,  and  form  a  swelling  at  the  posterior 
end  of  the  labium  majus.  The  course  corresponds  with  the  ascending 
branch  of  the  ischium.  It  usually  contains  a  part  of  the  small  intes- 
tine, but  the  large  intestine  and  the  omentum  have  also  been  found 
in  it. 

Diagnosis. — It  differs  from  anterior  labial  hernia  by  its  position 
farther  back,  by  the  freedom  from  swelling  of  the  space  between  it 
and  the  inguinal  canal  and  of  the  latter  itself,  and  by  being  reduci- 
ble, not  in  the  direction  of  the  external  inguinal  ring,  but  in  that  of 
the  vagina. 

The  diagnosis  from  other  affections  is  made  in  the  same  way  as 
just  pointed  out  for  the  anterior  variety. 

Treatment. — It  is  hard  to  hold  this  kind  of  hernia  back,  but,  as  it 
may  become  very  large,  the  attempt  should  be  made  with  vaginal 
pessaries,  of  which  an  inflatable  rubber  bag  would  be  most  likely  to 
answer,  or  a  truss.  Once  a  surgeon  obtained  retention  by  denuding 
the  mucous  membrane  in  a  circle  round  the  lower  end  of  the  hernia, 
doubling  it  up  and  stitching  it  together ;  after  thus  having  thickened 
the  integument  covering  it,  it  could  be  held  back  with  a  truss.1 

1  Winckel,  Die  Pathologic  der  Weiblichen  Sexualorgane,  Leipzig,  1881,  p.  284. 


262  DISEASES  OF  WOMEN. 


CHAPTER  III. 

TUMORS  CONNECTED  WITH  THE  EXTRAPELVIC  PORTION  OF  THE 
ROUND  LIGAMENT. 

In  connection  with  the  extrapelvic  portion  of  the  round  ligament 
may  be  found:  1,  hydrocele;  2,  hematocele  of  the  canal  of  Nuck ;  3, 
hematoma  of  the  round  ligament ;  and,  4,  fibroma  of  the  round  liga- 
ment. 

1.  Hydrocele*  is  a  swelling  due  to  an  accumulation  of  serum  in 
connection  with  that  part  of  the  round  ligament  which  lies  in  or 
below  the  inguinal  canal.  It  is  a  rather  rare  disease.  The  fluid 
may  be  contained  in  the  canal  of  Nuck  (p.  37),  or  in  the  surround- 
ing connective  tissue,  or  in  the  ligament  itself.  The  space,  if  formed 
by  the  canal  of  Nuck,  may  yet  communicate  with  the  abdominal 
cavity,  or  may  be  shut  off  from  all  connection  with  it  by  adhesion 
between  its  walls  at  the  upper  end.  It  is  covered  by  the  skin,  the 
superficial  fascia,  and  the  fascia  transversalis.  It  is  sometimes 
divided  into  several  compartments.  The  fluid  is,  as  a  rule,  serous 
and  of  a  slightly  greenish-yellow  color,  like  serous  collections  in 
other  parts  of  the  body,  but  in  traumatic  cases  it  may  be  more  or 
less  bloody,  and,  when  inflammation  occurs  in  the  sac,  it  may  become 
purulent  and  contain  gas.  It  begins  as  a  small,  painless,  oblong 
swelling  in  the  inguinal  canal,  and  extends  in  its  slow  growth  down 
into  the  anterior  part  of  the  labium  majus.  It  may  be  found  on 
both  sides.  At  first  it  often  disappears  when  the  patient  lies  on 
her  back  or  when  it  is  being  compressed.  If  the  fluid  is  found  in  a 
closed  sac,  the  swelling  is  immovable,  elastic,  not  very  tender  unless 
inflamed,  and  translucent,  as  the  corresponding  affection  of  the  tunica 
vaginalis  in  man.  It  may  become  as  large  as  a  child's  head  at  term, 
and  may  interfere  with  locomotion,  render  coition  impossible,  and 
oppose  a  serious  obstacle  to  childbirth. 

Diagnosis. — The  diagnosis  is  sometimes  difficult,  particularly  in 
regard  to  inguinal  hernia.  The  characteristic  points  are  the  slow 
development ;  the  disappearance  on  pressure  if  there  is  communica- 
tion with  the  peritoneal  cavity,  without  the  feel  of  any  solid  body 
being  displaced ;  the  elasticity  if  the  sac  is  closed ;  and  the  translti- 
cency.  When  inflamed,  hydrocele  may  cause  vomiting,  but  not  con- 
stipation, as  does  a  strangulated  hernia. 

Treatment. — If  the  sac  communicates  with  the  peritoneal  cavity,  it 
may  suffice  to  press  it  back  and  let  the  patient  wear  a  truss  until 
adhesion  takes  place  between  the  walls.  If  the  cavity  is  closed, 

1 A  comprehensive  article  on  this  subject  by  Wm.  C.  Wile  is  found  in  Amer.  Jour. 
Obst.,  1881,  vol.  xiv.  p.  584. 


DISEASES  OF  THE  VULVA.  263 

simple  aspiration  has  effected  some  cures*  If  that  does  not  suffice,  a 
few  drops  of  tincture  of  iodine  or  carbolic  acid  should  be  injected 
after  evacuating  the  fluid,  so  as  to  induce  adhesive  inflammation. 
During  the  injection  the  inguinal  canal  should  be  compressed,  and 
the  injected  fluid  should  be  sucked  out  again  with  the  syringe.  It 
may  become  necessary  to  make  an  incision,  fill  the  sac  with  iodoform 
gauze,  and  let  it  heal  from  the  bottom  by  granulation.  The  whole 
sac  has  also  been  extirpated.  If  the  contents  of  the  cyst  have  become 
purulent  or  sanious,  it  must  be  laid  open  and  thoroughly  washed 
with  disinfecting  fluids  (p.  205). 

2.  Hematocele  of  the  Canal  of  Nuck. — If  hydrocele  of  the  canal  of 
Nuck  is  rare,  hematocele  of  the  same  is  unique.1     In  the  only  case 
known  it  was  of  nine  years'  standing,  and  dated  from  childbirth.     It 
formed  a  tumor  of  the  size  of  a  large  hen's  egg  lying  on  the  descend- 
ing ramus  of  the  left  pubic  bone.     It  was  of  tense,  elastic  consistency, 
without  pain  or  tenderness  on  pressure,  and  covered  by  the  skin  of 
the  expanded  labium  majus  and  minus,  which  was  normal  and  mov- 
able.    Its  surface  was  smooth.     It  was  not  translucent,  could  not  be 
diminished   by  pressure,  did   not  increase  during  cough,  and  gave  a 
dull  sound  on  percussion.     From  its  upper  end  a  rather  hard  pedicle 
could  be  traced  into  the  inguinal  canal.     It  contained  a  thick  choco- 
late-colored mass  of  the  consistency  of  an  ointment.     The  wall  was 
hard  to  cut  through ;  the  cavity  was  entirely  regular  and  smooth. 

Diagnosis. — It  differs  from  intestinal  hernia  by  the  dull  percussion, 
the  immobility,  and  the  lack  of  increase  during  cough ;  from  hernia 
of  the  ovary  by  its  lack  of  sensitiveness ;  from  hydrocele  by  being  less 
soft  and  by  not  being  translucent ;  from  hematoma  of  the  vulva  by  the 
even  surface  and  its  chronic  course,  whereas  hematoma  of  the  vulva 
is  soon  absorbed  or  forms  an  abscess. 

Etiology. — Injury  (childbirth)  in  a  person  with  a  canal  of  Nuck 
the  lower  part  of  which  has  remained  open,  may  cause  an  extravasa- 
tion of  blood  into  that  cavity.  The  irritation  of  the  foreign  body 
causes  the  thickening  of  the  surrounding  membrane. 

Treatment. — A  long  incision  was  made,  the  contents  turned  out, 
the  sac  washed,  cauterized,  and  left  to  heal  by  granulation. 

3.  Hematoma  of  the  round  ligament  has  likewise,  so  far,  only  been 
found  once.2     It  consists  in  a  collection  of  blood  in  the  interior  of 
the  round  ligament.     When  operated  on  it  had  been  noticed  about 
four  years.     It  formed  a  tumor  in  the  right  inguinal  region  of  the 
size  of  a  hen's  egg,  and  had  been  taken  for  a  hernia.     The  surface 
was  smooth,  the  consistency  tense  and  elastic,  the  skin  normal  and 
movable  ovej*  the  tumor.     From  the  upper  end  a  pedicle  half  an  inch 
in  diameter  could  be  traced  into  the  inguinal  canal.     The  tumor  was 

1  Kobert  Koppe,  Centralblatt  f.  Gynak.,  1886,  vol.  x.  p.  179. 

2  Sigmund  Gottschalk,  Centralblatt  f.  Gynak.,  1887,  vol.  xi.  p.  329. 


264  DISEASES  OF  WOMEN. 

not  diminished  by  pressure,  nor  could  it  be  pushed  up  into  the 
inguinal  canal.  It  gave  a  dull  percussion-sounci,  and  was  not  trans- 
lucent. An  incision  was  made  through  skin,  subcutaneous  adipose 
tissue,  and  fascia,  the  tumor  easily  enucleated,  the  pedicle  tied  and 
cut  off,  and  the  edges  united  by  interrupted  silk  sutures,  without 
drainage-tube.  The  wound  healed  by  first  intention.  The  tumor 
proved  to  be  a  cyst,  the  wall  of  which  was  £  inch  thick.  The  con- 
tents were  a  dark  bloody  fluid.  Microscopical  examination  showed 
that  the  wall  was  composed  of  longitudinal  unstriped  muscle-fibers, 
and  that  the  fluid  was  blood. 

Diagnosis. — In  regard  to  intestinal  and  ovarian  hernia,  hematoma 
of  the  vulva,  and  hydrocele  we  refer  to  what  has  just  been  said  under 
Hematocele.  From  hematocele  of  the  canal  of  Nuck  it  may,  perhaps, 
be  diagnosticated  by  the  sensitiveness  and  pain  found  when  the  tumor 
is  situated  in  the  ligament,  and  consequently  is  dragged  upon  by  any 
movement  imparted  to  the  womb. 

Treatment. — To  what  has  been  already  said  is  only  to  be  added 
that  the  pedicle  ought  to  be  comprised  in  the  sutures,  so  as  to  avoid 
a  displacement  backward  of  the  womb. 

4.  Fibroma  of  the  Round  Ligament. — The  round  ligament  may 
become  the  seat  of  the  formation  of  a  fibrous  tumor  anywhere  in  its 
course  from  the  horn  of  the  uterus  through  the  pelvis  and  the  inguinal 
canal  to  the  groin  and  the  vulva.  The  situation  outside  of  the 
inguinal  canal  is  the  most  common.  The  tumor  appears  first  below 
the  external  inguinal  ring,  covering  the  inner  third  of  Poupart's  liga- 
ment, and  extends  by  growth  usually  down  into  the  labium  majus, 
more  rarely  up  through  the  inguinal  canal  and  along  the  anterior 
abdominal  wall  up  to  the  umbilicus.  In  the  beginning  it  is  more 
or  less  movable.  It  is  hard,  round,  painless,  and  covered  with  nor- 
mal skin.  Sometimes  a  pedicle  can  be  traced  to  the  inguinal  canal. 
It  grows  slowly,  and  has  been  found  varying  in  size  from  a  walnut 
to  a  cocoanut. 

Diagnosis. — The  diagnosis  is  often  difficult.  From  intestinal  and 
ovarian  hernia  it  differs  by  its  hardness,  lack  of  sensitiveness,  and 
lack  of  increase  during  cough ;  from  hydrocele,  by  its  hardness  and 
lack  of  pellucidity  ;  from  hematocele,  by  its  hardness ;  from  hematoma, 
by  its  chronic  course.  Chronic  inflammation  or  lympho-sarcoma  of 
an  inguinal  gland  forms  an  immovable  tumor,  without  pedicle,  and 
affects,  as  a  rule,  several  glands.  Diffuse  fibroma  of  the  vulva  begins 
in  the  labia  majora,  and  is  immovable. 

Prognosis. — In  itself  innocuous,  it  may  become  troublesome  by  its 
size  and  situation. 

Treatment. — It  is  easily  removed  by  an  incision  along  its  greatest 
diameter.  The  tumor  is  enucleated,  the  pedicle  tied  and  comprised 
in  the  sutures  uniting  the  edges. 


DISEASES  OF  THE  VULVA.  265 

CHAPTER    IV. 

INJURIES. 

THE  vulva  may  be  the  seat  of  bruises  or  wounds  in  consequence 
of  a  fall  on  some  sharp  object,  for  instance  the  back  of  a  chair  or  the 
edge  of  a  table,  or  of  blows  and  kicks.  The  injury  in  such  cases  is 
mostly  found  on  the  labia  majora.  On  account  of  the  sharp  edge  of 
the  ascending  ranius  of  the  ischium  and  the  descending  ramus  of  the 
pubes,  even  contact  with  a  blunt  object  may  cause  a  clear  cut. 

Coition  seldom  gives  rise  to  trail  matism  of  the  vulva  except  in 
cases  of  rape.  The  fossa  navicularis  may,  however,  be  penetrated, 
resulting  in  the  formation  of  a  permanent  vulvo- rectal  fistula.1 

Children  and  old  women  are  more  liable  to  injury  during  sexual 
connection,  on  account  of  the  lack  of  development  in  the  former,  and 
senile  involution,  with  loss  of  elasticity,  in  the  latter. 

Parturition  is  the  most  frequent  cause  of  injuries  to  the  vulva. 
Lacerations  of  the  perineum  will  be  considered  later.  Superficial 
tears  of  the  labia  majora  are  quite  common,  but  need  no  special  atten- 
tion if  my  antiseptic  occlusion  dressing  is  used.2  Sometimes  a  tear 
occurs  in  the  vestibule,  near  the  clitoris,  which  gives  rise  to  dangerous 
or  fatal  hemorrhage.3 

The  symptoms  vary  according  to  the  cause  and  the  degree  of  the 
violence.  If  the  skin  remains  unbroken,  there  are  pain,  soreness, 
swelling,  discoloration,  or  perhaps  subcutaneous  extravasation  of  blood 
(pudendal  hematoma).  If  the  skin  is  broken,  the  hemorrhage  is  often 
alarming  (p.  41). 

Treatment. — If  the  skin  is  unbroken,  the  pain  is  often  best  relieved 
by  hot-water  fomentations,  to  which  may  be  added  tinct.  of  arnica 
(3j  to  3j).  After  that  lead-and-opium  stupes  (tinct.  opii,  liq.  plumbi 
subacetat.,  da  3j ;  aquse,  .Iviij)  may  be  applied  with  advantage. 
If  the  hematoma  is  of  so  large  a  size  that  complete  resorption  is 
not  to  be  expected,  the  best  treatment  is  to  apply  Braun's  colpeu- 
rynter  filled  with  ice-water  in  the  vagina,  and  compression  on  the 
skin  for  three  or  four  days.  When,  then,  the  danger  of  hemor- 
rhage is  passed,  a  free  incision  is  made  on  the  internal  surface  of  the 
labium  majus,  parallel  and  near  to  its  lower  edge.  The  blood-clots 
are  turned  out,  and  the  cavity  washed  out  with  antiseptic  fluid,  pref- 
erably creolin,  on  account  of  its  hemostatic  properties.  If  any  vessels 
are  seen  bleeding,  they  should  be  tied  with  catgut,  or  if  there  is  oozing 
the  surface  should  be  seared  with  the  thermo-cautery.  Next  the  sac 

1  Joseph  Price,  Amer.  Jour.  Obst.,  1886,  yol.  xix.  p.  832. 

2Garrigues,  Practical  Guide  to  Antiseptic  Midwifery,  Detroit,  Michigan,  1886,  p.  27. 

3  Mund6,  Amer.  Jour.  Obst.,  1875,  vol.  viii.  p.  537. 


266  DISEASES  OF  WOMEN. 

is  packed  with  iodoform  gauze.     The  dressing  should   be  renewed 
every  day,  and  the  cavity  washed  out  with  antiseptic  fluid. 

If  an  abscess  is  formed,  the  pus  should  be  given  a  free  outlet  by 
incision,  and  the  wound  treated  antiseptically.  A  slight  tear  is 
dressed  with  iodoform  ointment  (p.  178).  If  there  is  any  hemor- 
rhage, a  careful  examination  should  be  made  for  its  source.  Spurting 
arteries  are  twisted  or  tied.  Bleeding  surfaces  are  brought  into  con- 
tact and  united  by  deep  sutures.  If  this  does  not  check  the  hemor- 
rhage, the  wound  should  be  covered  with  styptic  cotton  (p.  182),  the 
vagina  tamponed  (p.  179),  and  the  external  genitals  covered  with 
compresses  or  a  folded  towel  tightly  fastened  with  a  T-bandage.  A 
fistula  is  treated  by  paring  the  edges  and  uniting  them  with  silkworm 
sutures.  If  the  contusion  has  been  considerable  enough  to  cause  the 
death  of  the  tissue,  the  wound  should  be  kept  clean  with  an  antiseptic 
solution,  the  dead  tissue  cut  away  as  soon  as  feasible  after  a  line 
of  demarkation  has  formed,  and  the  wound  dressed  with  iodoform 
ointment. 


CHAPTER    V. 

VULVITIS. 

VULVITIS  is  inflammation  of  the  vulva.  It  appears  under  five 
different  forms:  the  catarrhal,  the  foUicular,  the  phlegmonous,  the 
venereal,  and  the  diphtheritic  inflammation. 

Etiology. — The  causes  of  catarrhal  and  follicular  vulvitis  are  lack 
of  cleanliness,  irritation  produced  by  discharges  from  the  uterus  or 
vagina,  or  from  the  bladder  if  the  patient  is  afflicted  with  a  vesico- 
vaginal  fistula;  masturbation,  excess  in  coition,  rape;  friction  pro- 
duced by  physical  exercise  in  fat  women ;  pin-worms  that  find  their 
way  from  the  anus  to  the  vulva,  and  ants  that  creep  in  from  the 
skin.  The  scrofulous  diathesis  predisposes  to  the  disease,  especially 
in  children. 

The  phlegmonous  form  may  result  from  the  catarrhal  or  be  caused 
by  violence.  It  is  mostly  found  in  prostitutes.  The  venereal  is  due 
to  infection  with  one  of  the  three  venereal  diseases,  gonorrhea,  chan- 
croid, or  syphilis.  The  diphtheritic  occurs  in  childbed  and  in  grave 
fevers,  such  as  scarlet  fever,  small-pox,  and  typhoid  fever. 

Symptoms. — The  catarrhal  vulvitis  is  either  acute  or  chronic.  The 
acute  is  more  common.  The  mucous  membrane  is  red,  swollen,  and 
covered  with  a  muco-purulent  secretion.  There  is  a  sensation  of  heat 
and  pain,  especially  smarting  during  micturition.  In  the  chronic 
form  the  mucous  membrane  is  of  a  less  bright  red  color,  and  often 
the  seat  of  abrasions  or  superficial  ulcers.  On  the  denuded  places 


DISEASES  OF  THE   VULVA. 


267 


the  papillae  are  hypertrophied  and  bleed  easily.  Redness  and  exco- 
riations are  often  found  in  the  groin  and  on  the  inside  of  the  thighs. 
Intolerable  itching  drives  the  patient  mad,  prevents  sleep,  and  may 
easily  lead  to  masturbation.  Sometimes  the  glands  of  the  groins- 
swell,  the  lymphatics  leading  to  them  from  the  excoriated  patches 
becoming  inflamed. 

In  foUicular  vulvitis  the  seat  of  the  inflammation  is  the  hair-follicles, 
the-  sebaceous  and  sudoriparous  glands,  and,  less  frequently,  the 
mucous  follicles,  the  intervening  mucous  membrane  remaining  healthy. 

FIG.  201. 


Follicular  Vulvitis  (Huguier). 

This  gives  a  peculiar  appearance  to  the  vulva,  the  labia  majora  and 
minora  being  studded  with  small  round  red  protuberances  of  the  size 
of  a  millet-seed  to  a  hemp-seed  (Fig.  201).  Often  a  hair  comes  out 
from  the  middle,  and  a  drop  of  pus  may  be  pressed  out  through  the 
center.  As  a  rule,  the  inflamed  follicle  bursts  and  shrivels  up,  but 
exceptionally  the  disease  may  end  in  induration,  when  small  hard 
nodules  remain  after  the  inflammation  has  run  its  course. 

In  phlegmonous  vulvitis  the  inflammation  extends  to  the  submucous 
and  subcutaneous  connective  tissue.  Deep  abscesses  and  sloughs  may 
form,  and  end  in  permanent  fistulous  tracts  if  not  properly  treated. 

Gonorrheal  vulvitis  is  much  like  the  simple  acute  catarrhal,  but 
redness  and  swelling  are  more  intense,  the  discharge  is  more  purulent, 


268  DISEASES  OF  WOMEN. 

and  the  inflammation  has  a  tendency  to  implicate  the  urethra,  and  is 
usually  accompanied  by  gonorrhea!  vaginitis.  Micturition  causes 
burning  pain,  the  urethra  is  swollen  and  tender,  and  a  drop  of  thick, 
creamy  pus  may  be  pressed  out  from  it.  In  children  the  veins  of  the 
labia  majora  and  minora  are  congested  and  varicose.  The  presence 
of  gouococci  may  be  revealed  by  the  microscope.  Valuable  as  these 
signs  are  from  a  diagnostic  standpoint,  they  are  not  so  pathognomouic 
that,  called  as  expert  in  a  lawsuit,  the  physician  should  not  be  careful 
not  to  be  too  positive  in  his  assertions.1  (See  below  under  Vaginitis.) 

Chanwoids  and  chancres  will  be  considered  under  Venereal  Diseases. 

Diphtheritic  vulvitis  is  characterized  by  the  formation  of  a  gray 
diphtheritic  membrane  on  and  in  the  mucous  membrane  or  wounded 
surfaces.  The  surrounding  parts  are  edematous,  dark  red,  or  other- 
wise discolored.  In  this  form  there  is  also  high  fever  and  general 
disturbance  of  the  whole  system. 

Prognosis. — The  acute  catarrhal  and  follicular  forms  are  of  little 
importance  and  short  duration.  The  chronic  form  may  be  very  pro- 
tracted. The  gonorrheal  may  extend  upward,  and  is  then,  as  we 
shall  see  later,  a  very  dangerous  disease.  The  infective  agent  has 
also  a  tendency  to  remain  in  Bartholin's  glands,  and  may  thus  cause 
infection  long  after  the  woman  is  seemingly  cured.  The  phlegmonous 
form  is  rather  serious.  The  diphtheritic  form  is  only  found  as 
part  of  the  most  severe  diseases.  Besides  endangering  the  patient's 
life,  it  may  lead  to  more  or  less  complete  destruction  of  important 
parts,  coalescence,  and  atresia  of  the  genital  canal. 

Treatment. — If  the  patient  is  feverish,  she  should  be  kept  in  bed, 
have  a  saline  aperient  and  aconite ;  in  the  diphtheritic  form  large 
doses  of  quinine  and  alcoholic  drinks,  and  in  the  later  stage  tinct. 
ferri  chloridi.  The  genitals  should  be  carefully  cleansed,  lukewarm 
or  hot  sitz-baths  given  two  or  three  times  daily ;  vaginal  injections 
with  carbolized  water  (p.  172)  should  be  used  as  often.  If  there  is 
any  irritating  discharge  from  the  uterus  or  the  vagina,  it  is  a  good 
plan  to  keep  it  away  by  means  of  a  cotton  ball  introduced  into  the 
vagina.  This  ball  ought  to  be  wrung  out  of  a  weak  antiseptic  fluid. 
The  genitals  should  be  covered  with  fomentations  of  the  same  de- 
scription, part  of  which  should  be  applied  between  the  labia.  When 
the  acutest  stage  is  over  the  lead-and-opium  wash  may  be  substituted 
for  the  carbolic  acid,  or  both  combined.  In  the  gonorrheal  form 
hydrargyrum  bichloride  is  preferable  for  injections  and  fomentations 
(p.  1721. 

Later,  the  mucous  membrane  of  the  vulva  may  be  painted  several 
times  daily  with  Monsel's  solution  of  subsulphate  of  iron  or  the  liq. 

1  The  reader  is  referred  on  this  point  to  the  timely  warning  of  so  high  an  authority 
as  Robert  W.  Taylor,  Atlas  of  Venereal  and  Skin  Diseases,  Philadelphia,  1888,  pp. 
57-58. 


DISEASES  OF  THE   VULVA.  269 

ferri  chloridi,  each  of  them  diluted  with  eight  parts  of  glycerin.  If 
this  does  not  effect  a  cure,  the  inflamed  parts  should  be  painted  every 
other  day  with  a  solution  of  nitrate  of  silver  (gr.  x-sj)  or  tinct. 
iodinii  co.,  diluted  with  two  parts  of  water.  When  the  mucous  mem- 
brane has  nearly  recovered,  dry  powders,  such  as  oxide  of  zinc,  sub- 
nitrate  of  bismuth,  iodoform,  or  even  inert  powders,  as  lycopodium, 
talcum,  or  corn  starch,  often  hasten  the  process.  These  same  powders 
are  used  for  the  accompanying  intertrigo. 

If  the  urine  is  alkaline,  benzoate  of  ammonium  or  sodium  should  be 
given  (gr.  x— xx  every  four  hours).  When,  on  the  other  hand,  the 
urine  is  too  acid,  bicarbonate  of  sodium  or  liquor  potassee  are  indi- 
cated: 

Ify.  Tinct.  belladonna?,  3ij  ; 

Liq.  potass.,  3J  ; 

Aquae,  ad  siv. 

M.     Sig.  A  teaspoouful  in  a  wineglassful  of  water,  t.  i.  cZ.). 

In  gonorrheal  urethritis  the  urethra  should  be  washed  out  with  hot 
water  or  flaxseed  tea  by  means  of  a  reflux  catheter.  When  the 
inflammation  subsides  somewhat,  carbolized  water  (J  per  cent.)  or 
corrosive  sublimate  (^  gr.  to  3j),  or  nitrate  of  silver  (-^  gr.  to  3j),  or 
chloral  hydrate  (gr.  x— 5J),  should  be  used.  Pain  may  be  relieved  by 
instillation  of  cocaine  with  a  glass  pipette.  If  necessary,  a  few  drops 
of  a  strong  solution  of  nitrate  of  silver  (gr.  x  to  xxx-sj)  may  be 
injected  or  applied  with  applicator  through  an  endoscope.  Antiblen- 
norrhagic  medicines  (copaiva,  cubebs,  and  sandal  oil)  should  only  be 
given  in  the  subacute  or  chronic  stage.  Itching  is  relieved  by  chloral 
hydrate,  camphor,  or  hydrocyanic  acid  : 

fy.  Chloral,  hydrat.,  3j-ij  ; 

Yaselini  albi,  gij. 

!£}.  Chlorali  hydrat., 

Camphorse,  da.  3j  ; 

Vaselini  albi,  Sij. 

I^j.  Acid,  hydrocyan.  dil.,  gij  ; 

Plumbi  acetat.,  9ij  ; 

Glycerini,  gij. 

1^.  Chlorali  hydrat., 

Camphorse,  dd.  3ij ; 

Acidi  oleici,  §ij. 

When  nothing  else  will  help,  the  whole  mucous  membrane  must 
be  excised. 

In  the  phlegmonous  form  abscesses  should  be  laid  open  by  free 


270  DISEASES  OF  WOMEN. 

incisions,  washed  out  with  disinfectants,  and  filled  with   iodoform 
gauze. 

Parts  affected  with  diphtheritic  infiltration  should  be  cauterized 
with  chloride  of  zinc  dissolved  in  equal  parts  of  distilled  water.1 
The  healing  process  should  be  carefully  watched,  so  as  to  avoid  sec- 
ondary deformities. 


'CHAPTER  VI. 
INFLAMMATION  OF  THE  URETHRAL  DUCTS. 

THE  urethral  ducts  described  on  p.  76  may  become  inflamed. 
Their  mouths  are  then  seen  outside  of  the  meatus  in  consequence  of 
the  swelling  and  prolapse  of  the  mucous  membrane.  They  appear 
like  very  small  ulcers  of  a  yellowish-gray  color,  surrounded  by  a 
deep-red  circle,  and  a  purulent  fluid  may  be  pressed  out  of  them. 
The  lower  third  of  the  urethra  is  sometimes  swollen.  It  is  exquis- 
itely tender  to  touch,  and  causes  the  patient  much  discomfort,  but 
micturition  is  not  particularly  painful. 

Treatment. — The  ducts  should  be  washed  out  by  injecting  carbolized 
water  or  the  saturated  solution  of  boracic  acid.  If  a  more  active 
treatment  is  needed,  tincture  of  iodine  or  a  strong  solution  of  nitrate 
of  silver  (1  :  4)  may  be  injected,  or  a  fine  probe  covered  with  nitrate 
of  silver  in  substance  may  be  introduced  into  them.  In  a  recalci- 
trant case  I  obtained  a  cure  by  introducing  a  probe  and  slitting  the 
canals  open  from  the  vagina  with  Paquelin's  thermo-cautery  (p.  182). 


CHAPTER  VII. 
GANGRENE  OF  THE  VULVA. 

THE  vulva  may  become  gangrenous  in  consequence  of  contusion, 
or  overdistension  due  to  edema  or  extravasated  blood,  or  from  the  use 
of  a  tampon  with  undiluted  liquor  ferri  chloridi  (p.  179).  Gangrene 
may  also  be  caused  by  inflammation,  especially  diphtheritic  infiltra- 
tion. It  occurs  sometimes  in  eruptive  fevers.  An  idiopathic  gan- 
grene identical  with  noma  is  found  in  young  children,  and  is  said  to 
be  contagious.  It  begins  as  a  white  blister,  which  soon  changes  into 
an  ulcer,  that  takes  a  diphtheritic  aspect  and  becomes  gangrenous. 
It  is  a  dangerous  disease,  usually  ending  in  septicemia. 

1  For  the  details  of  this  treatment  I  must  refer  the  reader  to  my  other  writings: 
"Puerperal  Diphtheria,"  Trans.  Amer.  Gyn.  Soc.,  1885,  vol.  x.  p.  109;  "Puerperal 
Infection,"  Amer.  Syst.  Obst.,  ii.  p.  363 ;  Antiseptic  Midwifery,  p.  61. 


DISEASES  OF  THE   VULVA.  271 

Treatment. — The  affected  part  should  be  cauterized  with  a  50  per 
cent,  solution  of  chloride  of  zinc,  or  with  the  thermo-cautery,  and 
covered  with  iodoform  or  compresses  dipped  into  a  saturated  solution 
of  chlorate  of  potash.  Tonics  and  stimulants  should  be  used  freely. 
As  soon  as  a  line  of  demarkation  is  formed  the  dead  tissue  should 
be  removed. 


CHAPTER   VIII. 

EXANTHEMATOUS    DISEASES. 

IN  exanthematous  fevers  the  genitals  may  be  the  seat  of  an  erup- 
tion like  other  parts  of  the  body.  They  may  also  be  attacked  by 
skin  diseases,  such  as  furunculosis,  erythema,  eczema,  etc. ;  but  as 
these  diseases  offer  nothing  peculiar  in  this  region,  and  are  treated  as 
in  other  parts,  the  reader  is  referred  in  regard  to  them  to  works  on 
the  practice  of  medicine  and  skin  diseases.  Only  one  exudative  skin 
disease  shall  be  described  here,  on  account  of  its  frequent  occurrence 
and  great  diagnostic  importance — viz.  herpes. 

Herpes  Progenitalis. — Herpes  progenitalis  is  a  mild  inflammatory 
affection,  consisting  of  one  or  more  vesicles  or  groups  of  vesicles. 
The  eruption  may  occur  without  any  prodromal  symptoms,  but  in 
most  cases  it  is  preceded  by  a  burning  and  itching  sensation. 

First  appears  a  small  round  red  spot.  On  this  the  epidermis  is 
soon  raised,  forming  a  vesicle  of  the  size  of  a  pin-head  to  a  hemp-seed, 
filled  with  clear  serum.  This  ruptures  and  leaves  a  shallow  ulcer  of 
the  size  of  the  vesicle.  Its  floor  is  at  first  of  a  deep  rosy  red,  with 
a  finely  uneven  surface  and  its  edges  sharply  cut  as  with  a  punch, 
and  sometimes  undermined,  but,  as  a  rule,  not  to  the  same  extent  as 
in  chancroid.  Sometimes  there  is  so  much  edema  of  the  labia  minora 
that  the  eruption  is  concealed  until  they  are  separated.  On  the  skin 
the  vesicle  is  followed  by  a  scab.  The  disease  lasts  from  a  few  days 
to  two  weeks,  but  is  apt  to  return.  It  may  lead  to  the  development 
of  a  bubo. 

Etiology. — It  is  due  to  congestion  and  inflammation  of  the  genitals 
and  pelvic  organs.  It  is  only  found  in  adults,  especially  in  prosti- 
tutes. It  appears  often  as  a  concomitant  of  menstruation. 

Diagnosis. — It  may  be  very  like  a  chancre  in  the  erosive  stage, 
but  this  has  a  deeper  and  duller  red,  coppery  color,  and  its  floor  is 
smooth  and  shining,  without  the  small  granulations  found  in  herpes. 
Its  areola  is  very  slight  and  of  a  dark  red  color,  and  there  is  a  gen- 
eral absence  of  inflammation  about  the  lesion.  On  pressure  a  chan- 
crous  erosion  does  not  yield  any  fluid,  while  a  herpetic  vesicle  gives 
issue  to  several  drops.  The  history  may  also  offer  some  help  to  a 


272  DISEASES  OF  WOMEN. 

diagnosis,  but  it  is  advisable  to  be  a  little  reserved  until  we  see  the 
course  the  disease  takes. 

Treatment. — The  parts  should  be  cleansed  and  all  irritation  avoided. 
Milder  cases  get  speedily  well  when  covered  with  lint  soaked  in — 

fy.  Acidi  carbol.,  TTLxl  j 

Glycerini,  3ss ; 

Aquae,  ad  3iv. 

The  dry  powders  mentioned  above  (see  Vulvitis,  269)  hasten  the 
healing,  and  the  iodoform  ointment  (p.  178)  relieves  pain.  Persistent 
neuralgic  and  burning  pains  require  cauterization  with  carbolic  acid 
or  a  strong  solution  of  nitrate  of  silver  (1 :  8),  followed  by  the  lead- 
and-opium  wash.1 

CHAPTER    IX. 
TRICHIASIS. 

INVERSION  of  the  hairs  of  the  labia  is  a  rare  condition  which  causes 
intense  itching.  The  offending  hairs  must  be  removed  and  their 
bulbs  destroyed  by  electrolysis. 


CHAPTER   X. 
PRURITUS  VULV.E. 

PRURITUS  VULVJE  is  characterized  by  an  itching  sensation  on  the 
inner  or  outer  surface  of  the  vulva,  sometimes  extending  up  into  the 
vagina  or  over  the  lower  half  of  the  abdominal  wall.  It  may  be 
symptomatic  or  idiopathic.  When  it  is  symptomatic  it  may  be  a 
symptom  of  a  disease  of  the  genitals,  especially  follicular  vulvitis, 
eczema  pudendi,  or  trichiasis,  or  it  may  be  a  reflex  symptom  of  disease 
in  other  organs,  such  as  hemorrhoids,  pin-worms  in  the  rectum,  diseases 
of  the  kidneys,  ureters,  bladder,  or  urethra,  congestion  of  the  pelvic 
organs,  etc. 

Predisposing  causes  are  pregnancy,  menstruation,  the  menopause, 
old  age,  the  gouty  diathesis,  or  general  nervousness.  Sometimes  the 
itching  is  due  to  direct  irritation  by  parasites  (lice  or  acarus  scabiei), 
acrid  discharges  from  the  vagina  or  uterus,  or  urine  containing  sugar. 

In  other  cases  no  cause,  near  or  remote,  can  be  found,  and  then  it 
has  been  surmised  that  the  disease  is  located  in  the  nervous  centers. 

1  For  further  details  the  reader  is  referred  to  Robert  W.  Taylor's  Atlas  of  Venereal 
and  -Stin  Diseases,  Philadelphia,  1888,  p.  72. 


DISEASES  OF  THE   VULVA.  273 

Symptoms. — The  chief  symptom  is  an  itching  that  is  so  violent  that 
it  irresistibly  drives  the  patient  to  scratch  herself,  a  procedure  which 
gives  a  momentary  relief,  paid  for  by  increased  itching.  The  scratch- 
ing produces  excoriations  and  inflammatory  conditions,  especially 
eczema,  which,  again,  contribute  to  the  morbid  sensation. 

In  its  higher  degrees  the  disease  is  a  very  serious  one.  The  patient 
scratches  so  that  she  wears  off  the  hair  of  the  rnons  Veueris  and 
labia  majora ;  she  avoids  company ;  she  becomes  melancholy  and 
morose ;  she  loses  her  appetite ;  her  sleep  is  disturbed ;  she  becomes 
the  victim  of  an  abnormally  increased  sexual  desire  or  contracts  the 
habit  of  masturbation ;  she  may  finally  become  insane,  succumb  to 
exhaustion,  or  end  her  miserable  existence  by  suicide. 

The  itching  may  be  continuous,  but  is  more  frequently  interrupted 
by  free  intervals  of  hours  and  days.  It  increases  by  heat,  and  is, 
therefore,  worse  at  night,  in  a  warm  room,  and  during  physical 
exertion. 

Prognosis. — The  prognosis  depends  on  the  possibility  of  removing 
the  cause.  If  no  cause  can  be  found,  it  is  often  very  obstinate,  and 
sometimes,  it  would  seem,  incurable. 

Treatment. — First  of  all,  we  must  try  to  find  and  remove  the  cause. 
If  there  are  crab-lice  among  the  hairs  on  the  pubes,  the  hairs  should 
be  cut  short  or  shaved  off,  and  the  skin  smeared  with  blue  ointment 
or  Peruvian  balsam,  or  washed  with  a  strong  solution  of  corrosive 
sublimate  (1  gr.  to  alcohol  and  water  da.  gss),  and  general  warm 
baths  with  2  drachms  of  the  same  drug  should  be  given. 

If  the  acarus  scabiei  is  the  offender,  as  a  rule  a  treatment  for  itch 
of  the  whole  body  will  be  needed.  Locally,  beta-naphthol  in  vaseline 
(gr.  xxv  to  §j)  or  sulphur  ointment  should  be  rubbed  in. 

Inflammation  of  the  vulva  must  be  treated  as  described  above 
(p.  260).  Eczema  is  treated  with  unguent,  diachyli.  Pin-worms  are 
removed  from  the  rectum  by  means  of  extr.  sennse  et  spigelise  fl.  (§ss, 
t.  i.  d.\  given  by  the  mouth,  and  rectal  injections  of  a  strong  infusion 
of  quassia  (Bij-Oj)  or  corrosive  sublimate  (gr.  ^  in  gviij  of  water). 
Hemorrhoids,  glycosuria,  and  other  diseases  causing  the  pruritus 
should  be  treated  according  to  the  rules  of  medical  and  surgical 
practice. 

The  diet  is  of  great  importance.  Besides  the  special  diet  called  for 
by  diabetes  and  gout,  alcoholic  drinks  and  spiced  food  should  be 
avoided.  The  food  should  be  nourishing,  but  bland.  Milk  in  large 
quantities  (two  or  three  quarts  a  day)  is  to  be  recommended  if  it  can 
be  digested.  If  it  causes  dyspepsia  in  its  natural  state,  it  should 
be  tried  boiled,  skimmed,  or  peptonized. 

The  general  treatment  should  be  tonic,  sedative,  and  narcotic. 
Arsenic  and  quinine  are  particularly  recommended.  Bromide  of 
potassium  in  large  doses  (3J-ij  daily)  is  often  very  valuable.  Tinct. 

18 


274  DISEASES  OF  WOMEN. 

cannabis  Indica  (20  to  40  drops,  L  i.  d.)  is  preferable  to  opium.  It 
may  be  necessary  to  procure  sleep  by  means  of  chloralamid,  sulphonal, 
urethane,  trional,  or  the  other  modern  hypnotics. 

The  local  treatment  is  of  the  greatest  importance.  Vaginal  injec- 
tions and  affusions  of  plain  hot  water,  solutions  of  carbolic  acid, 
bichloride  of  mercury,  or  borax  should  be  freely  used  many  times  a 
day.  If  any  irritating  discharge  dribbles  from  the  vagina,  relief  is 
obtained  by  keeping  it  back  by  means  of  a  cotton  tampon  wrung  out 
of  some  mild  antiseptic  solution.  The  vulva  may  be  covered  with 
fomentations  of  lead-water  with  or  without  opium  or  the  saturated 
solution  of  potassium  bromide,  or  painted  several  times  a  day  with 
glycerin  mixed  with  chloroform  (1  : 8),  hydrocyanic  acid  (p.  269), 
or  morphine  (gr.  ij  or  iij  to  3j),  or  the  parts  may  be  painted  at  longer 
intervals  with  a  10  per  cent,  solution  of  cocaine  in  water,  a  similar 
solution  of  carbolic  acid,  or  a  strong  solution  of  nitrate  of  silver  (p. 
269),  followed  by  cold  applications.  For  base  of  ointment  vaseline 
is  the  best.  It  may  be  mixed  with  acetate  of  lead,  chloral,  camphor 
(p.  269),  or  chloroform  (of  each  3J-3J).  The  affected  part  may  be 
rubbed  with  a  menthol  stick  or  solid  nitrate  of  silver.  Some  claim 
to  have  successfully  applied  the  galvanic  current.1  As  a  last  resort, 
when  everything  else  had  failed,  the  removal  of  the  affected  portions 
of  skin  or  mucous  membrane  by  cutting  instruments  has  effected  a 
cure  in  several  cases. 

During  pregnancy  only  the  milder  of  the  above-named  remedies 
may  be  used.  Large  and  frequent  vaginal  injections  must  be  avoided. 
A  tampon  soaked  in  equal  parts  of  sulphurous  acid  and  glyceratum 
boracis  may  be  introduced  into  the  vagina.  One  case  is  reported  in 
which  tobacco-smoking  gave  relief. 

Burning  Sensation  in  the  Genitals  and  the  Abdomen. — This  affec- 
tion is  probably  nearly  related  to  pruritus,  but  differs  from  it  in  the 
character  of  the  sensation.  It  is  not  very  rare — in  my  experience,  if 
anything,  more  common  than  its  universally  recognized  sister,  and 
still  itself  is  hardly  mentioned  anywhere.  It  seems  to  be  fully  as 
recalcitrant  to  treatment,  if  not  more  so.  Applications  of  compresses 
soaked  in  cold  water  to  the  abdomen,  the  above-mentioned  vaginal 
injections,  and  bromide  of  potassium  internally  have  given  me  the 
best  results. 

1  W.  Blackwood,  Polydinic,  Philadelphia,  1885,  No.  9,  vol.  ii.  p.  141. 


DISEASES  OF  THE   VULVA.  275 

CHAPTER  XL 

HYPERESTHESIA  OF  THE  VULVA. 

DR.  T.  G.  THOMAS  has  described,  under  the  name  of  hyperesthesia, 
a  disease  of  the  vulva  that  is  sufficiently  well  marked  to  deserve  a 
special  place  in  the  system  of  gynecological  diseases.1  Although  by 
no  means  frequent,  it  is,  according  to  him,  not  a  very  rare  disease, 
either.  It  consists  in  an  excessive  sensibility  of  the  nerves  supplying 
the  mucous  membrane  of  some  part  of  the  vulva. 

The  slightest  friction  excites  intolerable  pain  and  nervousness ; 
even  a  cold  and  unexpected  current  of  air  produces  discomfort;  and 
any  degree  of  pressure  is  absolutely  intolerable.  Sexual  intercourse 
is,  therefore,  hateful  or  impossible — a  condition  elegantly  called  dys- 
pareunia  (p.  121). 

The  disease  appears  near  or  at  the  menopause ;  hysteria  and  despond- 
ency predispose  to  it.  Sometimes  it  is  found  combined  with  vulvitis 
or  a  painful  urethral  caruncle,  but  in  other  cases  no  cause  can  be 
found.  It  differs  from  pruritus  by  the  absence  of  itching,  and  from 
vaginismus  by  not  causing  any  spasmodic  contraction  of  the  vagina. 

The  treatment  is  unsatisfactory.  Even  the  complete  destruction 
of  the  mucous  membrane  of  the  sensitive  area  with  caustics  or  its 
removal  with  the  knife  has  failed  to  produce  a  permanent  cure. 
Sexual  intercourse  should  be  absolutely  forbidden.  If  feasible,  the 
patient  should  be  sent  away  from  home  to  a  place  offering  healthful 
surroundings  and  cheerful  company.  The  general  treatment  should 
consist  in  tonics,  sea-baths  or  warm  general  baths,  and  massage. 
The  local  affection  should  be  treated  with  hot  sitz-baths,  injections, 
and  affusions,  and  calmative,  astringent,  and  derivative  applications, 
as  detailed  in  the  preceding  chapter. 


CHAPTER  XII. 

TUMORS  OF  THE  VULVA. 

1.  Hyperplasia. — "Without  containing  diseased  tissue,  parts  of  the 
vulva  may  acquire  abnormally  large  proportions.  Thus  we  have  seen 
that  the  labia  minora  in  certain  races  become  enormously  developed 
(p.  37),  and  that  in  some  individuals  the  clitoris  may  have  the  size 
of  the  male  organ  (p.  256). 

1  T.  Gaillard  Thomas,  A  Practical  Treatise  on  the  Diseases  of  Women,  6th  ed., 
Philadelphia,  1891,  p.  150. 


276  DISEASES  OF  WOMEN. 

2.  Varicose  Veins. — The  veins  of  the  vulva,  especially  of  the  labia 
majora,  may  swell  so  as  to  form  tumors  of  considerable  size,  even 
that  of  the  fetal  head. 

This  condition  is  in  most  cases  connected  with  pregnancy,  but  may 
occur  independently  thereof.  It  is  produced  by  everything  that 
obstructs  the  free  flow  of  venous  blood  from  the  vulva,  such  as 
tumors  pressing  on  the  pelvic  veins,  lifting  of  heavy  burdens,  pro- 
tracted standing,  habitual  constipation,  etc. 

The  swollen  veins  form  dark  blue,  nearly  black,  globular,  oval,  or 
serpentine  soft  swellings,  that  collapse  on  pressure,  and  refill  immedi- 
ately when  the  pressure  is  discontinued.  They  increase  during  preg- 
nancy, and  become  smaller  after  the  birth  of  the  child ;  but  often 
they  do  not  disappear  altogether.  They  cause  an  uncomfortable  sen- 
sation of  heat  and  weight,  especially  during  bodily  exertion,  and 
sometimes  pruritus.  They  may  burst  spontaneously,  but  usually 
that  accident  is  produced  by  the  passage  of  the  child  or  by  external 
injury.  If  the  skin  holds,  a  hematoma  is  formed ;  if  it  breaks,  a 
serious,  and  sometimes  fatal,  hemorrhage  follows  (p.  41). 

Treatment. — During  pregnancy  the  patient  should  rest  in  a  recum- 
bent position  in  the  middle  of  the  day,  in  order  to  relieve  the  pressure 
of  the  child  on  the  veins  of  the  pelvis.  At  times  even  complete  rest 
in  bed  or  on  a  lounge  is  indicated.  Fomentations  with  lead-water 
relieve  heat  and  tension.  A  pad  may  be  adapted  in  such  a  way  as 
to  compress  the  swelling.  The  patient  should  be  informed  of  the 
dangers  of  hemorrhage,  and  instructed  how  to  check  it  by  compression 
till  she  can  get  help.  When  a  rupture  has  taken  place  and  the  blood 
escapes,  the  hemorrhage  should  be  controlled  by  means  of  deep 
sutures,  tamponade  of  the  vagina  and  vulva  (pp.  179-180),  combined 
with  pressure  on  the  skin  by  means  of  a  compress  rolled  so  as  to 
form  a  hard  cylinder  placed  against  the  cutaneous  surface  of  the  labia 
majora  and  retained  with  a  T-baudage. 

3.  Hematoma,  or  thrombus,  is  a  swelling  due  to  extravasation  of 
venous  blood  in  the  connective  tissue  of  the  vulva.     It  is  most  com- 
mon in  the  labium  majus,  and,  as  a  rule,  it  affects  only  one  side. 

Varicose  veins  predispose  to  hematoma.  The  exciting  causes  are 
external  violence,  such  as  a  blow  or  a  fall,  and  straining,  especially 
during  childbirth. 

The  hematoma  may  consist  in  a  small  swelling  of  the  size  of  a  hazel- 
nut  or  acquire  the  dimensions  of  a  fist  or  a  fetal  head  at  term.  It  is 
of  dark  blue  or  purple  color  and  tender  on  pressure.  The  blood  may 
be  absorbed  or  the  tumor  may  become  inflamed,  suppurate,  and  even 
fall  a  prey  to  gangrene.  When  inflammation  sets  in,  swelling,  ten- 
derness, and  heat  increase,  the  skin  takes  a  brighter  purple  .color,  the 
temperature  rises,  and  symptoms  of  septicemia  may  develop.  The 
swelling  may  oppose  a  serious  obstruction  to  the  passage  of  the  child 


DISEASES  OF  THE   VULVA.  277 

or  cause  retention  of  urine.  It  may  also  burst,  causing  the  dangerous 
hemorrhage  just  mentioned.  As  a  complication  of  delivery  it  has 
proved  fatal  in  20  per  cent,  of  the  cases  reported. 

Treatment. — A  small  hematoma  may  be  let  alone  or  treated  with 
cold,  astringent,  or  absorbent  fomentations  (ice-bag,  ice- water  coil, 
lead-and-opium  wash,  arnica).  If  it  is  larger  than  a  fist,  it  should 
be  at  once  opened  with  a  long  incision,  the  clots"  turned  out,  bleeding 
veins  secured  by  suture  or  forcipressure  (p.  184),  and  the  cavity 
packed  with  iodoform  gauze  or  styptic  cotton.  As  soon  as  pus  is 
formed  the  hematoma  must  under  all  circumstances  be  opened  and 
thoroughly  disinfected. 

4.  Papilloma  is  a  tumor  produced  by  hyperplasia  of  the  papillae 
of  the  skin  or  mucous  membrane,  with  corresponding  development 
of  the  blood-vessels  and  epidermis.  It  appears  on  the  female  genitals 
in  three  well-marked  forms :  common  warts,  vegetations,  and  mucous 
patches. 

Warts,  generally  of  round  form,  more  or  less  pediculated,  of  the 
size  of  a  pea  or  a  bean,  with  a  dry,  uneven  surface  of  dark  brown 
color,  are  occasionally  found  on  the  skin  of  the  vulva,  especially  the 
mons  Veneris,  as  in  other  parts  of  the  body.  They  are  insignificant, 
and  do  not  call  for  any  treatment. 

Vegetations,  also  called  venereal  warts  or  condylomata  acuminata, 
stand  in  special  relation  to  the  genitals,  male  and  female.  They  are 
often  found  in  patients  suffering  from  gonorrhea,  chancroid,  or 
syphilis,  especially  gonorrhea,  but  may  also  be  entirely  independent 
of  any  venereal  affection,  and  are  then  due  to  lack  of  cleanliness. 
They  are  most  common  on  the  fourchette,  at  the  vaginal  entrance, 
and  the  labia  minora  or  niajora,  but  may  extend  through  the  whole 
vagina  and  to  the  vaginal  surface  of  the  vaginal  portion  of  the  uterus, 
the  inside  of  the  thighs,  and  around  the  anus.  On  the  mucous  mem- 
brane they  are  soft;  on  the  skin  they  are  harder.  They  begin  as 
small  erosions,  which  soon  change  to  pin-head-sized  granular  papules. 
After  that  they  grow  rapidly,  forming  sessile  or  pediculated,  club-  or 
•cockscomb-shaped  protuberances.  Their  color  varies  much  :  some  are 
light  gray,  others  are  pink,  deep  red,  or  purplish.  They  vary  in 
size  from  a  hemp-seed  to  a  raspberry,  but  if  neglected  the  different 
isolated  growths  come  in  contact  with  one  another  and  may  form  a 
tumor  as  large  as  the  fetal  head.  Their  surface  shows  always  pro- 
tuberances separated  by  deep  furrows,  and  they  can  be  separated  into 
smaller  cauliflower-like  parts  springing  from  a  narrow  base.  They 
exhale  a  mucoid  secretion  of  a  sickening  odor.  Even  the  dry  vege- 
tations on  the  skin  are  apt  to  become  eroded  and  secrete  such  fluid. 
The  acrid  secretion  may  cause  vulvitis  and  vaginitis,  and  the  tumors 
may  mechanically  obstruct  the  meatus  urinarius,  the  vaginal  entrance, 
and  the  anus,  so  as  to  interfere  with  micturition,  coition,  defecation, 


278  DISEASES  OF  WOMEN. 

and  childbirth.  When  they  are  destroyed  new  ones  are  very  prone 
to  spring  up.  In  elderly  persons  they  have  a  tendency  to  become 
malignant  and  change  into  epithelioma.  The  secretion,  if  carried 
into  the  eyes,  is  apt  to  cause  purulent  ophthalmia.  During  childbirth 
there  is  the  same  danger  for  the  eyes  of  the  baby,  and  besides  that 
the  risk  of  puerperal  infection  of  the  mother.  The  tumors  may  also 
become  gangrenous,  and  in  that  way  cause  the  patient's  death. 

Diagnosis. — Flat  and  broad  vegetations  may  sometimes  be  so  like 
mucous  patches  that  one  affection  may  be  mistaken  for  the  other ;  but 
with  mucous  patches  we  have  the  history  of  preceding  syphilitic 
infection  and,  as  a  rule,  other  concomitant  symptoms  of  syphilis. 
They  are  few  in  number,  and  develop  more  slowly. 

Treatment. — The  sooner  these  tumors  are  removed  the  better.  If 
they  are  small,  they  may  be  snipped  off  with  curved  scissors  or 
scraped  off  with  the  sharp  spoon,  after  which  the  base  should  be 
touched  with  liq.  ferri  chloridi  or  the  actual  cautery.  They  may 
also  be  destroyed  with  corrosive-sublimate  collodium  (3ss— §j)  or  sali- 
cylic acid  dissolved  in  collodium  (3J-BJ),  glacial  acetic  acid,  lactic, 
nitric,  or  chromic  acid,  and  other  caustics.  The  tincture  of  Thuya 
occidentalis  is  said  to  be  a  specific  for  these  growths.  They  should 
be  constantly  moistened  with  it.  In  my  experience  the  thermo-cau- 
tery  has  proved  the  only  radical  cure  even  for  small  vegetations. 

If  they  are  of  medium  size — up  to  an  inch  in  diameter — they 
may  be  tied  with  a  silk  or  rubber  ligature.  If  they  are  still  larger, 
the  galvano-caustic  wire  is  the  best  means  for  their  removal. 

At  the  same  time,  great  cleanliness  should  be  inculcated.  Vaginal 
douches  with  carbolic  acid  or  corrosive  sublimate,  hot  sitz-baths,  and 
hot  affusions  should  be  used  several  times  a  day.  The  affected  sur- 
faces should  be  kept  dry  and  separated  with  antiseptic  gauze. 

If  operation  is  contraindicated,  even  large  tumors  can  be  made  to 
shrink  by  covering  them  with  equal  parts  of  calomel  and  salicylic 
acid.1  If  these  vegetations  have  invaded  the  meatus  urinarius,  care 
must  be  taken  to  use  methods  that  will  not  cause  stricture. 

Even  during  pregnancy  vegetations  should  be  removed  by  some  of 
the  above-named  means,  since  they  present  a  double  danger  for 
mother  and  child.  Minor  operations  may  be  performed  with  cocaine 
(1  :  8  or  10) ;  the  larger  require  etherization. 

Mucous  patches  will  be  considered  later. 

To  papilloma  seems  also  to  belong  a  disease  that  has  been  de- 
scribed under  the  name  of  oozing  tumor.  It  is  a  very  rare  disease 
if  it  is  not  simply  the  same  as  large  flat  vegetations.  It  is  said  to 
occur  mostly  in  middle-aged,  fat  women.  It  forms  a  large  flat  tumor 
on  one  or  both  labia  majora,  divided  with  deep  fissures,  and  is  cha- 
racterized by  discharging  a  large  amount  of  an  acrid,  offensive  fluid. 
1  E.  W.  Taylor,  1.  c.,  p.  30. 


DISEASES  OF  THE   VULVA.  279 

In  a  case  operated  on  by  Dr.  Emmet l  with  knife  and  sutures  the 
hemorrhage  was  profuse.  It  is  therefore  preferable  to  remove  the 
mass  with  the  thermo- cautery  or  galvano-cautery. 

5.  Elephantiasis,  or  pachydermia,  is  a  chronic  recurring  inflamma- 
tion of  lymph-vessels  accompanied  by  hyperplasia  of  the  connective 
tissue,  the  skin,  mucous  membrane,  and  epidermis,  leading  to  the 
formation  of  large  tumors. 

Etiology. — Sporadic  cases  are  very  rarely  found  in  North  America 
and  Europe,  but  the  disease  is  endemic  in  the  West  Indies,  the  coasts 
of  Central  and  South  America,  Africa,  and  on  the  islands  of  the 
Pacific.  It  is  mostly  found  in  adults,  but  seems  to  begin  in  child- 
hood. The  dark  races  are  much  more  frequently  affected  than  the 
white.  It  occurs  especially  in  marshy  localities.  It  is  mostly  due  to 
the  presence  of  a  parasite  called  filaria  sanguinis  in  the  blood,  in 
which  it  is  supposed  to  be  introduced  through  mosquito-bites.  It 
may  also  be  due  to  primary  occlusion  of  lymphatics  and  destruction 
of  the  lymphatic  glands  of  the  groin. 

Symptoms. — The  endemic  form  begins  with  all  the  symptoms  of 
lymphangitis.  The  patient  is  feverish ;  the  affected  part  becomes 
swollen  and  red ;  the  redness  may  follow  the  lymphatics  or  blood- 
vessels as  red  streaks,  or  cover  the  whole  surface  as  in  erysipelas.  The 
inguinal  glands  become  swollen  and  tender.  This  acute  stage  lasts  a 
week  or  two,  subsides  slowly,  and  leaves  often  the  parts  in  an  ede- 
matous  condition.  After  that  there  follows  a  free  interval  varying 
in  length  from  a  month  to  several  years,  when  the  same  process  is 
repeated,  each  attack  leaving  the  affected  part  more  swollen  and 
harder,  until  all  pitting  ceases  and  the  tissue  becomes  hard  as  the 
rind  of  ham.  The  skin  has  a  dark  color.  The  surface  may  be 
smooth  or  rough,  covered  with  warts,  the  seat  of  fissures,  or,  when 
the  tumor  is  rubbed,  ulcerations  may  form  and  allow  a  serous  fluid  to 
ooze  out.  Most  frequently  the  labia  majora  are  the  seat  of  the  dis- 
ease, after  them  the  clitoris,  and  most  rarely  the  labia  minora.  The 
tumors  may  reach  such  a  size  that  they  hang  down  to  the  knees  or 
even  to  the  ankles,  and  weigh  many  pounds.  They  prevent  sexual 
connection,  and  cause  discomfort  by  their  bulk  and  weight,  but  they 
do  not  affect  the  general  health.  They  do  not  become  strictly  pedun- 
culated,  but  when  they  are  large  the  base,  however,  is  somewhat  nar- 
rower than  the  middle  of  the  tumor.  Exceptionally  they  may  give 
rise  to  thrombosis  and  pyemia.  Chyluria  is  a  frequent  accompani- 
ment of  elephantiasis. 

Pathological  Anatomy. — The  swelling  is  chiefly  situated  in  the 
skin  and  mucous  membrane;  the  lymphatics  are  dilated  and  the 
papillae  enlarged.  The  underlying  subcutaneous  connective  tissue  and 
the  epidermis  are  also  increased  in  thickness.  In  the  tissue  compos- 

1 L.  c.,  p.  603. 


280  DISEASES  OF  WOMEN. 

ing  these  tumors  are  found  yellow  elastic  fibers  and  deposits  of  pig- 
ment. According  to  the  different  consistency  of  the  tumors  the  tissue 
contains  more  or  less  serum. 

Diagnosis. — It  differs  from  diffuse  fibroid  by  the  history  of  a  fever- 
ish beginning  or  repeated  attacks  of  lymphangitis.  The  inguinal 
glands  are  often  affected.  Not  only  the  connective  tissue,  but  the 
skin  itself,  is  thickened.  When  the  tumors  are  examined  micro- 
scopically, we  find  dilated  lymph-spaces  and  yellow  elastic  fibers. 

Prognosis. — The  disease  never  disappears  spontaneously,  and  is 
only  curable  in  the  beginning.  Its  progress  extends  over  many 
years.  It  does  not  shorten  life  except  in  the  rare  cases  of  thrombosis 
and  pyernia. 

Treatment — During  the  acute  stage  antipyretics  and  cold  applica- 
tions are  used.  Change  of  climate  is  desirable.  In  young  subjects 
sulphide  of  calcium  (gr.  1-1 J,  twice  a  day)  is  claimed  to  have  effected 
a  cure  in  a  month  or  two.  Massage  and  electrolysis  may,  under 
similar  circumstances,  prove  useful  and  may  be  combined  with  it. 
In  cases  of  long  standing  amputation  is  the  only  remedy.  This  may 
be  performed  in  different  ways : 

a.  Schroeder's  method  is  to  cut  from  below  upward,  a  small  part 
at  a  time,  and  unite  the  edges  by  deep  sutures  before  progressing 
with  the  operation. 

6.  Mund6  introduced  long  pins  through  the  base  of  the  tumor, 
surrounded  it  with  a  temporary  elastic  ligature,  cut  the  tumor  off, 
loosened  the  ligature,  tied  bleeding  vessels,  and  united  the  edges. 

c.  Silver-wire  sutures  may  be  drawn  through  the  base  before  cut- 
ting, the  vessels  tied  with  catgut,  and  the  sutures  closed. 

d.  The  tumor  may  be  removed  with  the  galvano-caustic  wire  or 
the  thermo-cautery. 

The  cutting  operations  are  preferable,  since  there  is  good  hope  of 
obtaining  complete  or  partial  union  by  first  intention. 

6.  Fibroma. — A  fibroid  or  fibroma  is  a  tumor  composed  of  fibrous 
connective  tissue.  It  occurs  in  the  vulva  in  two  forms — the  diffuse 
and  the  circumscribed. 

The  etiology  is  obscure. 

The  diffuse  fbroma  is  much  like  elephantiasis  in  appearance,  and 
the  seat  is  the  same ;  but  while  in  elephantiasis  the  chief  thickening 
takes  place  in  the  skin  and  the  mucous  membrane,  the  fibroma  is 
formed  by  hyperplasia  of  the  connective  tissue,  without  growth  of 
the  skin  and  mucous  membrane.  The  tumors  are  more  or  less  irregu- 
lar, often  divided  into  lobes  or  shooting-off  pedunculated  portions. 
The  skin  covering  them  is  pink,  whitish,  or  brownish.  They  have 
no  intrinsic  tendency  to  ulceratiou,  but  through  friction  superficial 
ulcers  may  form,  and  again  heal  up,  leaving  cicatrices.  These 
tumors  are  not  sensitive  nor  the  seat  of  spontaneous  pain,  except 


DISEASES  OF  THE   VULVA.  281 

•when  they  become  inflamed.  They  grow  slowly,  but  may  become 
very  large.  They  do  not  affect  the  constitution,  but  incommode 
the  patient  by  their  size  and  weight,  and  are  a  hindrance  to  coition, 
sometimes  amounting  to  complete  dyspareuuia. 

Minute  Anatomy. — The  microscope  shows  connective-tissue  fibers, 
with  infiltration  of  round  cells  surrounding  the  vessels,  but  no  change 
in  the  vessels  themselves  or  the  skin,  and  no  yellow  elastic  fibres ; 
which  features  distinguish  fibroma  from  elephantiasis. 

Treatment — Amputation  is  the  only  remedy,  and  is  carried  out  as 
stated  under  Elephantiasis. 

The  circumscribed  fibroma  is  a  rare  affection.  It  is  composed  of 
the  same  tissue  as  the  diffuse  form,  but  soon  becomes  pedunculated, 
and  hangs  down  from  the  labium  majus. 

The  treatment  consists  in  cutting  the  pedicle  near  its  base,  tying 
with  catgut  the  artery  that  nourishes  it,  and  uniting  the  edges  with 
sutures. 

7.  Myoma,  Myxoma,  Lipoma. — Tumors  entirely  similar  to  fibromas 
may  be  formed   of  unstriped   muscle-fibers  (myoma)  •  of  a  delicate 
fibrous  reticulum,  the  meshes  of  which  contain  a  homogeneous  basis- 
substance  and  cells  (myxoma)  •  or  of  adipose  tissue  (lipoma).     Quite 
commonly  the  different  kinds  of  tissue  are  intermingled  with  more 
or  less  fibrous  tissue,  forming  myo-fibromas,  myxo-fibromas,1  etc.    They 
are  all  benign,  but  the  only  treatment  is  amputation.2 

8.  Enchondroma  of  the  Clitoris? — A  single  case  has  been  reported 
of  a  pedunculated  tumor,  of  the  size  of  a  fist,  attached  to  the  clit- 

1  On  account  of  the  great  rarity  of  these  tumors,  I  may  be  pardoned  for  stating 
that  on  March  12,  1884,  I  removed  one  from  a  Swedish  cook,  set.  34 :  it  had  been 
first  noticed  nine  years  before.  It  hung  from  the  middle  of  the  left  labium  majus, 
to  which  it  was  attached  by  a  pedicle  of  the  length  and  thickness  of  a  finger.  The 
tumor  itself  was  pear-shaped,  measured  8  centimeters  in  length,  7  from  side  to  side, 
and  4  in  thickness.  It  had  the  color  of  normal  skin,  and  was  covered  with  peeling- 
off'  epidermis.  At  the  lower  end  was  seen  an  irregular  slough  of  the  size  of  a  fifty- 
cent  piece,  surrounded  by  a  suppurating  line  of  demarkation  which  exhaled  an 
offensive  odor.  In  the  pedicle  was  felt  a  pulsating  artery  of  the  size  of  the  umbilical, 
and  in  it  and  near  it  on  the  labium  majus  were  varicose  veins.  The  tumor  did  not 
cause  any  pain,  nor  was  it  tender  on  pressure.  I  put  a  clamp  on  the  base  of  the 
pedicle,  formed  two  small  flaps,  tied  the  artery,  and  united  the  edges  with  catgut. 
it  healed  by  first  intention.  When  cut  open  a  moderate  amount  of  blood  flowed 
from  the  tumor;  the  surface  was  smooth,  the  skin  not  thickened,  but  so  intimately 
connected  with  the  tumor  that  it  could  not  be  dissected  off'.  Microscopical  exam- 
ination proved  it  to  be  a  myxo-fibroma.  1  have,  in  St.  Mark's  Hospital,  seen  a  case 
almost  entirely  like  the  preceding  one. 

4  Geo.  M.  Tuttle  of  New  York  has  removed  a  large  fibroma  mottuscum  from  the 
labium  majus.  It  measured  17i  in.  in  circumference ;  had  a  thick  capsule,  in  cut- 
ting through  which  the  appearance  was  strikingly  like  gut :  thin,  translucent,  gas- 
eous in  feeling,  and  very  resonant  on  percussion  (Amer.  Jour.  Obstet.,  June,  1891, 
vol.  xxiv.  p.  715). 

3  Tumors  of  the  clitoris  are  extremely  rare.  Grace  Peckham  has  described  a  cysi 
as  large  as  a  hen's  egg,  and  collected  twenty  cases  of  different  kinds  of  tumors  of  this 
organ  (Amer.  Jour.  Obstet.,  Oct.,  1891,  vol.  xxiv.  pp.  1153-1172). 


282  DISEASES  OF  WOMEN. 

oris,  and  composed  of  a  cartilaginous  mass,  which  in  some  places 
was  softened,  in  others  hard  as  a  stone,  probably  through  calcareous 
deposit.  No  microscopical  examination  seems  to  have  been  made. 
The  treatment  was,  of  course,  removal  of  the  tumor. 

9.  Horn  of  the  clitoris  is  likewise  a  gynecological  curiosity.     A 
case  is  reported  of  a  horny  mass,  in  size  and  shape  like  the  talon  of 
a  tiger,  growing  under  the  prepuce  of  the  clitoris.     Such  a  growth 
might  wound  the  male  during  coition,  and  ought  to  be  removed  with 
the  thermo-  or  galvano-cautery. 

10.  Urethral  Caruncle,  Angioma,  and  Neuroma  of  the   Vulva. — 
The  names  urethral  caruncle,  vascular  tumor  of  the  urethra,  painful 
tumor  of  the  urethra,  and  irritable  vascular  excrescence  of  the  urethra 
have  been  applied  to  a  kind  of  growths  found  at  or  near  the  meatus 
urinarius,  and  characterized  by  their  great  vascularity.     It  is  a  quite 
common  affection,  and  is  often  seen  accidentally  in  patients  examined 
for  other  complaints,  without  causing  any  symptoms.     On  the  other 
hand,  it  may  cause  great  pain,  especially  during  micturition,  and  be 
so  tender  to  the  touch  that  sexual  intercourse  is  rendered  hateful  or 
impossible.     Even  the  friction  of  the  clothes  may  suffice  to  start  the 
pain.     Sometimes  there  is  only  one  such  tumor,  in  other  cases  many. 
They  are  usually  found  just  at  the  meatus,  but  may  also  develop  more 
or  less  high  up  in  the  urethra.     They  are  sessile  or  pediculated,  of 
bright   red   color,  usually  sensitive,  and   apt  to   bleed   after   small 
injuries.     They  vary  in  size  from  a  hemp-seed  to  a  cherry.     Even 
when  thoroughly  destroyed  they  are  apt  to  recur,  or  new  ones  may 
spring  up  in  the  neighborhood  of  the  first. 

Microscopical  examination  has  shown  that  these  tumors  are  full  of 
dilated  capillaries  and  nerve-fibers,  with  hyperplasia  of  the  papillae 
and  connective  tissue.  Anatomically  speaking,  they  are,  therefore, 
angiomas  and  sometimes  neuromas.  The  different  composition  ac- 
counts probably  for  the  great  difference  in  symptoms. 

Vascular  tumors  (angiomata)  and  nervous  tumors  (neuromata)  form 
in  rare  cases  small  tumors  on  other  parts  of  the  vulva  and  the  peri- 
neum. 

Diagnosis. — The  bright  red  color,  the  great  sensitiveness  (when 
found),  their  insertion  at  the  meatus,  and  their  even,  globular  surface, 
make  them  easily  distinguishable  from  vegetations. 

Treatment. — The  only  thing  that  affords  help  is  the  removal  of  the 
tumor.  If  there  is  a  thin  pedicle,  it  needs  only  to  be  twisted  off  with 
a  pressure-forceps.  Small  sessile  tumors  may  be  destroyed  with 
chromic  or  nitric  acid,  neutralizing  the  superfluous  acid  by  bathing 
the  parts  with  a  solution  of  bicarbonate  of  soda.  Cocaine  (10  per 
cent.)  may  be  used  for  local  anesthesia.  Larger  sessile  tumors  are 
best  removed  with  the  thermo-  or  galvano-cautery  under  general 
anesthesia.  In  the  interior  of  the  urethra  they  must  be  exposed  with 


DISEASES   OF  THE   VULVA.  283 

a  urethral  speculum  (p.  150),  especially  Jackson's,  and  cut  or  scraped 
off  or  destroyed  with  caustics.  The  latter  should  even  be  used  on 
the  base  after  cutting  or  scraping,  in  order  to  prevent  recurrence. 

11.  Cysts. — Except  those  situated  in   the  vulvo- vaginal   glands, 
which  will  be  considered   later,  cysts  of  the  vulva  are  rather  rare. 
They  are  single  or  multiple,  and  range  in  size  from  that  of  a  pea  to 
that  of  a  fetal  head.     They  differ  much  in  origin.     Some  are  dermoid 
cysts,  with  the  characteristic  hairs,  bones,  and  teeth  in  the  interior. 
Others  are  atheromas,  formed  by  occlusion  of  a  sebaceous  follicle,  and 
contain  a  pultaceous  mass.     Most  of  them  are  filled  with  a  serous 
fluid.     Some  seem  to  be  due  to  an  old  extravasation  of  blood  or  to 
expansion  of  lymphatic  vessels. 

If  small,  they  do  not  give  rise  to  any  symptoms,  but  if  they  acquire 
large  proportions,  they  may  incommode  the  patient  by  their  weight 
and  size,  and  cause  dyspareunia.  If  they  become  inflamed,  they  are 
painful,  and  are  accompanied  by  fever  and  other  systemic  disturbances. 

Treatment. — As  they  are  intimately  connected  with  the  surrounding 
tissue,  it  may  be  difficult  to  enucleate  them.  If  so,  a  part  of  the  wall 
is  excised,  the  interior  cauterized,  packed  with  iodoform  gauze,  and 
left  to  heal  by  granulation. 

12.  Cancer. — Compared  with  the  uterus,  the  vulva  is  rarely  the 
starting-point  of  cancer.     Different  kinds  are  found  here — epithelioma, 
medullary  carcinoma,  atrophic  carcinoma  (or  scirrhus),  and  sarcoma,. 
with  its  variety  melano-sarcoma,  the  cells  of  which  contain  brown  pig- 
ment.    They  are  all  malignant,  tending   toward   local  destruction, 
undermining  the  constitution,  and  ending  in  death. 

Epithelioma  (Fig.  202)  is  in  so  far  less  malignant  than  the  other 
varieties  of  cancer  as  its  course  is  slower. 

Etiology. — Cancer  appears  mostly  after  the  fortieth  year,  but  has 
even  been  found  in  childhood.  Psoriasis  of  the  parts  has  a  tendency 
to  become  cancerous.  Otherwise  the  cause  is  unknown. 

Symptoms. — The  most  common  starting-point  is  the  sulcus  between 
the  labiurn  majus  and  minus  or  the  lower  edge  of  the  labium  majus, 
more  rarely  the  clitoris  or  the  meatus  urinarius.  It  begins  as  small 
nodules  in  the  skin  or  mucous  membrane,  covered  with  an  increased 
mass  of  epithelium,  which  often  causes  distressing  itching.  Later, 
these  nodules  become  excoriated,  secrete  a  thin,  malodorous  fluid, 
form  ulcerations  that  become  confluent,  and  spread  over  the  neigh- 
boring parts.  Soon  the  inguinal  glands  become  swollen.  The  ulcers 
are  irregular,  have  discolored  margins,  an  elevated  floor,  and  are  often 
covered  with  a  new  growth  of  cancerous  tissue,  which  gives  them  the 
appearance  of  a  raspberry.  They  have  no  tendency  to  enter  the 
vagina.  They  are  liable  to  bleed  and  cause  pain.  Sometimes  the 
surroundings  become  hard  as  a  board,  and  the  vaginal  and  urethral 
openings  may  become  obstructed. 


284 


DISEASES  OF  WOMEN. 


Prognosis. — The  patients  usually  succumb  at  the  end  of  two  or 
three  years. 

Diagnosis — Lupus  heals  in  one  place  while  destruction  extends  in 
another,  is  not  so  hard,  causes  slight  pain,  and  is  inodorous.  The 


FIG.  202. 


Epithelioma  of  Vulva  (P.  Zweifel) :  a,  clitoris ;  b,  fossa  navicularis ;  c,  vaginal  entrance ;  d, 
torn  perineum ;  gg,  cancerous  nodules  in  the  skin. 

inguinal  glands  swell  late  or  not  at  all.  The  general  health  remains 
good.  Chancroid  is  not  indurated,  has  sharply-cut,  perpendicular 
edges,  and  the  inguinal  glands  are  implicated  much  sooner.  Chan&'e 
presents  a  surface  much  like  that  of  the  excoriated  cancer  nodule,  and 
has  the  indurated  floor,  but  the  history,  the  early  appearance  of 
adenitis,  and  the  development  of  other  syphilitic  symptoms  will  soon 
clear  up  the  diagnosis.  Mucous  patches,  even  if  excoriated,  do  not 
form  destructive  ulcers,  and  disappear  soon  under  local  and  general 
treatment. 

Treatment. — The  nodules  and  ulcers  ought  to  be  eradicated  at  once. 
If  possible,  it  should  be  done  with  knife  and  scissors,  and  the  edges 
united  by  deep  sutures,  which  allows  of  union  by  first  intention ; 
otherwise  the  therm o-  or  galvano-cautery  is  used.  If  the  urethra 
is  implicated,  as  much  of  it  as  feasible  should  be  left,  in  order  not  to 


DISEASES  OF  THE   VULVA.  285 

interfere  with  the  retentive  power.  If  the  inguinal  glands  are 
affected,  they  must  be  enucleated,  but  even  if  they  are  removed  en- 
tirely, the  disease  cannot  be  arrested  permanently. 

13.  Lupus,  Esthiom&ne  (Huguier) ;  Chronic  Inflammation,  Infiltra- 
tion, and  Ulceration  (R.  W.  Taylor). — The  doubtful  position  of  lupus 
of  the  vulva  in  the  system  of  gynecological  diseases  necessitates  an 
exception  from  the  rule  followed  in  this  work  not  to  enter  into  his- 
torical developments.  In  1849,  Huguier,  a  French  physician,  de- 
scribed a  disease  of  the  vulvo-aual  region  under  the  name  of  esthio- 
m&tie,  which  was  claimed  to  be  identical  with  lupus  as  found  especially 
on  the  face.  The  name  "  lupus"  has  prevailed,  and  a  certain  number 
of  cases  have  been  reported  in  different  countries.1 

The  pathology  of  lupus  itself  is  not  yet  settled,  and  so  much  the 
less  can  we  decide  whether  the  disease  attacks  the  external  female 
genitals  or  not.  According  to  Koch's  great  authority,  lupus  is  simply 
tuberculosis  of  the  skin,  and  only  that  affection  which  is  caused  by 
the  presence  of  his  bacillus  tuberculosis  deserves  the  name ;  but  this 
microbe  has  so  far  been  looked  for  in  vain  in  lupus  vulvse.  Others 
claim  that  an  infiltration  with  small  round  cells,  clustering  together  in 
nodules,  especially  around  the  capillary  vessels  of  the  skin,  or  a  diffuse 
infiltration  of  the  papillary  layer  or  around  the  glands  and  hair-follicles 
of  the  skin,  constitutes  lupus.  Still  others  lay  particular  stress  on  the 
presence  of  giant  cells  in  the  clusters  of  small  round  cells.  Others, 
again,  contend  that  all  this  is  not  characteristic  of  lupus,  but  may 
be  found  in  any  inflammation  with  formation  of  granulation  tissue 
and  proliferation  of  the  cells  of  the  connective  tissue.2  R.  "W. 
Taylor3  denies  altogether  the  existence  of  lupus  in  the  female  geni- 
tals. Based  on  his  large  experience  in  Charity  Hospital,  he  includes 
all  the  inflammations  and  infiltrations  of  the  vulva  of  non-malignant 
origin  in  the  following  categories : 

1.  Small  hyperplasiffi,  caruncles,  and  papillary  growths; 

2.  Large  hyperplasiae. 

3.  Hyperplasia  resulting  from  acute  and  chronic  chancroids ; 

4.  Indurating  edema  of  syphilis ; 

5.  Hyperplasia  resulting  from  chronic  ulcers,  so-called  chancroids, 
in  intermediary  and  old  syphilis ; 

6.  Hyperplasia  in  old  syphilitics,  presenting  no  specific  character 
and  occurring  soon  or  long  after  the  period  of  gummy  infiltration,  in 
some  cases  being  coexistent  with  specific  lesions  elsewhere. 

The  cases  of  formation  of  tumors,  combined  with  ulceration,  con- 

1  Grace  Peckham,  in  an  excellent  paper  fortified  by  microscopical  examinations 
by  H.  C.  Coe  (A'mer.  Jour.  Obst.,  1887,  vol.  xx.  p.  78o),  has  collected  48  cases,  of 
which  she  eliminates  some  as  tubercular,  carcinomatous,  or  not  ulcerative,  and 
retains  33,  inclusive  of  her  own. 

2  Coe,  1.  c.,  Ira  Van  Gieson  in  R.  W.  Taylor's  paper. 
SR.  W.  Taylor,  X.  Y.  Med.  Jour.,  Jan.  4,  1890. 


286 


DISEASES  OF  WOMEN. 


stituting  the  condition  commonly  called  lupus  vulvse,  that  have  come 
under  my  own  observation,  were  all  developed  on  a  foundation  of 
recent  or  old  syphilis. 

What  has  been  called  lupus  vulvse  (Fig.  203)  consists  in  ulcera- 
tive  lesions  of  the  vulva  characterized  by  their  slow  development, 


FIG.  203. 


Lupus  of  Vulva  (Haberlin). 

absence  of  pain,  a  violaceous  color,  thickening,  induration,  and  forma- 
tion of  detached  tumors.  Hyperplasia  and  destruction  go  hand  in 
hand,  but  the  hyperplastic  process  preponderates.  The  deformity 
extends  often  to  the  perineum  and  the  anus.  The  inguinal  glands 
may  become  swollen,  but  are  oftener  not  affected.  The  general 
health  stays  good  for  years,  and  those  who  are  not  cured  succumb 
usually  to  constriction  of  the  intestine  and  peritonitis.  Locally,  great 
destruction  takes  place.  Fistulous  tracts  may  burrow  into  the  labia 


DISEASES  OF  THE    VULVA.  287 

and  around  the  rectum,  and  fistulse  may  open  into  the  urethra,  the 
bladder,  or  the  rectum.  Fortunately,  this  destructive  hyperplastic 
affection  of  the  vulva  is  a  rare  disease. 

Etiology. — Those  who  do  not  look  upon  the  ulcerative  hyperplasia 
of  the  vulva  as  a  disease  sui  generis,  attribute  it  to  the  large  vascular 
and  nervous  supply  of  the  genitals,  to  the  injuries  they  are  frequently 
exposed  to,  to  their  dependent  position  between  the  thighs,  to  lack  of 
cleanliness  and  care,  and  the  irritation  caused  by  uterine  or  vaginal 
discharges. 

Diagnosis. — Epiihelioma  is  usually  more  localized,  of  much  greater 
density — even  to  stouiness — is  productive  of  a  large  warty  or  papilla- 
matous  and  ulcerated  surface,  and  is  very  soon  accompanied  by 
•enlargement  of  the  inguinal  lymphatic  glands.  The  ulceratious  of 
•epithelioma  are  upon  the  surface,  while  those  in  so-called  lupus  are 
mostly  found  in  interstices,  fissures,  and  at  the  base  of  tumors.  Epi- 
thelioma gives  rise  to  lancinating  pain ;  lupus  is  painless  or  causes 
only  smarting  or  pruritus,  especially  after  micturition.  The  discharge 
that  emanates  from  the  ulcers  in  lupus  has  little  or  no  odor.  An 
ulcerated  part  may  heal  spontaneously  or  in  consequence  of  treatment, 
but  the  cicatrice  is  liable  to  be  affected  by  a  new  growth  of  lupus. 
The  microscope  settles  the  question  with  certainty  by  showing  the 
epithelioma  to  contain  cancer-nests  of  concentrically  arranged  cells  of 
the  epithelial  type. 

Prognosis. — We  have  already  stated  that  the  disease  is  a  very 
tedious  one,  extending  over  years.  It  does  not  in  itself  undermine 
the  constitution,  but  may  lead  to  intestinal  obstruction  and  peritonitis 
or  general  exhaustion.  In  patients  over  forty  any  vulvar  tumor, 
even  a  caruncle  or  a  papilloma,  may  degenerate  and  become  cancerous. 
If  not  checked,  the  disease  may  cause  great  destruction,  and  give  rise 
to  much  annoyance  by  perforating  the  partitions  between  the  different 
hollow  pelvic  viscera  and  the  external  genitals. 

Treatment. — On  account  of  the  dangers  lurking  in  the  background 
treatment  ought  to  be  quite  active.  The  indication  is  to  remove 
tumors  and  heal  ulcers.  Simon's  sharp  spoon,  strong  caustics — e.  g. 
nitric  acid,  the  thermo-cautery,  the  galvano-cautery,  the  galvano- 
caustic  wire — may  all  be  used  to  advantage,  but,  if  possible,  it  is 
preferable  to  cut  away  all  diseased  tissue  and  unite  the  edges  with 
sutures.  Fistulous  tracts  may  be  laid  open  by  means  of  the  elastic 
ligature.  It  goes  without  saying  that  the  utmost  cleanliness  should 
be  practised  by  means  of  baths,  fomentations,  and  injections.  Often 
a  tonic  treatment  with  iron,  quinine,  cod-liver  oil,  etc.,  or  local  or 
general  antisyphilitic  treatment,  may  be  called  for  in  combination 
with  the  mechanical  local  treatment. 


288  DISEASES  OF  WOMEN. 

CHAPTER  XIII. 
TUBERCULOSIS. 

TUBERCULOSIS  of  the  vulva  is  an  exceedingly  rare  affection  ;  which 
is  strange,  since  one  would  think  that  occasions  of  direct  inoculation, 
either  from  the  same  or  another  individual,  by  means  of  fingers, 
handkerchiefs,  towels,  or  the  sexual  act,  would  present  themselves 
frequently.  But  the  fact  is  that  the  more  we  approach  the  surface 
of  the  body  the  rarer  becomes  tuberculosis  in  the  genital  system. 

It  forms  ulcers  with  sharp  edges,  sinuous  contour,  and  a  depressed 
grayish-yellow  bottom  covered  with  a  cheesy  detritus.  Around  the 
ulcers  are  often  found  small  opaque,  yellow  nodules.  In  the  dis- 
charge of  the  ulcers  and  in  the  tissue  forming  them  and  the  nodules 
are  found  tubercle  bacilli.  In  the  mucous  membrane  are  found  clus- 
ters of  polygonal  cells  surrounded  by  a  zone  of  small  round  cells,  and 
containing  giant  cells,  in  the  interior  of  which  may  be  found  tubercle 
bacilli.  As  a  rule,  similar  affections  will  be  found  in  other  parts  of 
the  genitals  and  in  the  lungs. 

Treatment. — The  general  treatment  is  the  same  as  for  tuberculosis 
in  other  parts — nutritious  diet,  tonics,  sunshine,  and  fresh  air.  The 
local  treatment  consists  in  application  of  tincture  of  iodine  or  iodoform. 
If  this  does  not  suffice  to  eradicate  the  disease,  removal  with  the  knife 
or  destruction  with  caustics  or  cautery  is  indicated  in  the  early  stages. 
If  the  patient  is  far  gone,  more  palliative  treatment  with  the  curette 
and  iodoform  or  aristol  is  all  that  should  be  attempted. 


CHAPTER  XIV. 

PROGRESSIVE  ATROPHY  OF  THE  NYMPH^E  (L.  TAIT),  KRAUROSIS 

(BREISKY). 


AT  or  after  the  menopause,  and  quite  exceptionally  in  younger 
years,  is  sometimes  found  a  peculiar  atrophy  of  the  mucous  membrane 
of  the  inner  side  of  the  labia  minora.  It  begins  as  small  red  spots, 
depressed  under  the  level  of  the  surrounding  mucous  membrane,  ten- 
der and  prone  to  bleed,  transitory  or  spreading.  They  may  disappear 
in  one  place  and  reappear  in  another,  or  spread  serpiginously.  Later, 
the  mucous  membrane  contracts,  so  as  to  cause  considerable  coarcta- 
tion  of  the  vestibule.  The  stenosis  may  be  so  great  that  hardly  a 
finger  can  be  introduced  into  the  vagina.  Coition  becomes  painful, 
and  childbirth  is  accompanied  by  tears  of  the  tissues.  When  the  dis- 
ease is  fully  developed,  the  labia  minora  seem  to  be  absent.  The 


DISEASES  OF  THE  VULVA.  289 

mucous  membrane  appears  dry,  smooth,  and  cicatricial.  Sometimes 
there  is  a  slight  yellow  discharge.  In  many  cases  itching  or  burning 
is  complained  of. 

The  cause  of  the  disease  is  unknown.     Its  course  is  very  slow. 

Pathological  Anatomy. — Microscopical  examination  of  the  red  spots 
shows  dilated  capillaries,  with  thinned  walls,  and  nerve-fibers.  All 
over  the  aifected  part  of  the  mucous  membrane  the  rete  mucosum  is 
thin,  so  that  in  many  places  the  horny  epidermis-cells  lie  directly  on 
the  papillae.  These  are  of  uneven  length,  mostly  short ;  the  papillary 
body  is  composed  of  straight  fibers  like  a  cicatrice,  and  the  sebaceous 
and  sudoriferous  glands  disappear. 

Treatment. — Kraurosis  vulvse  is  a  very  intractable  disease.  Cocaine 
is  said  to  increase  the  sufferings.  Applications  of  strong  carbolic  acid 
and  a  pledget  steeped  in  a  saturated  solution  of  acetate  of  lead  are 
recommended.  A  cure  has  been  obtained  by  cutting  the  aifected  part 
of  the  mucous  membrane  away  and  uniting  by  sutures.  It  may  also 
be  destroyed  with  the  thermo-  or  galvano-cautery. 


CHAPTER  XV. 
DISEASES  OF  THE  VULVO-VAGINAL  GLANDS. 

THE  vulvo-vaginal  glands  may  be  the  seat  of  catarrh,  cystic 
degeneration  and  abscess. 

1.  Catarrh  of  the  gland  is  rare.     It  is  characterized  by  hypersecre- 
tion  of  mucus  and  redness  of  the  mucous  membrane  surrounding  the 
opening.     The  duct  may  become  dilated,  so  that  a  uterine  sound  may 
be  passed  through  it,  or  it  may  become  closed,  and  then  a  retention 
cyst  is  formed.     Sometimes  the  accumulated  secretion  may  be  thrown 
off  in  paroxysms,  constituting  a  kind  of  nocturnal  emission. 

The  treatment  is  not  satisfactory.  The  duct  should  be  dilated  with 
probes,  and  astringent  antiseptic  fluids  injected.  On  account  of  the 
emissions,  it  has  been  recommended  to  extirpate  the  glands. 

2.  Oysts. — There  may  be  a  superficial  or  a  deep  cyst.     The  former 
is  supposed  to  be  formed  by  the  duct.     It  forms  a  small  round  tumor 
immediately  under  the  mucous  membrane,  just  outside  the  vaginal 
entrance.     It  may  vary  in  size  from  that  of  a  hazeluut  to  that  of  a 
hen's  egg.     The  deep  cyst  is  situated  in  the  gland  itself,  and  may  be 
unilocular  or  multilocular.     It  forms  a  large  tumor  which  is  situated 
in  the  posterior  part  of  the  labium  majus.     Both  form  well-defined 
globular  or  oval,  elastic  tumors.     The  contents  are  ordinarily  like  the 
raw  white  of  an  egg,  but  may  be  chocolate-colored  from  admixed 
blood  or  purulent  when  inflammation  has  taken  place.     As  a  rule,  the 
duct  is  closed,  but  by  increased  pressure  it  sometimes  opens  again.    If 

19 


290  DISEASES  OF  WOMEN. 

not  inflamed,  these  cysts  are  indolent,  but  they  may  cause  some  dis- 
comfort by  their  size  and  be  an  obstacle  to  sexual  intercourse. 

The  most  common  cause  is  gonorrheal  infection. 

Diagnosis. — Hydroeele  is  situated  more  forward,  below  the  external 
inguinal  ring.  The  same  applies  to  anterior  labial  hernia.  Hernia 
of  the  ovary  is  harder,  and  pressure  on  it  causes  a  peculiar  sickening 
feeling.  Posterior  labial  hernia  can  be  replaced  through  the  vagina. 
Vulvar  abscess  has  less  distinct  limits,  is  more  tender,  and  the  skin  is 
red.  Abscess  of  the  gland  is  tender,  hot,  red,  and  accompanied  by 
fever. 

Treatment. — Part  of  the  contents  may  be  drawn  out  with  a  hypo- 
dermic syringe,  and  replaced  by  an  injection  of  chloride  of  zinc 
(1  to  10).  The  contents  may  be  withdrawn  entirely,  and  an  injection 
made  with  pure  tincture  of  iodine  or  a  5  per  cent,  solution  of  car- 
bolic acid.  The  anterior  wall  may  be  cut  off,  the  cavity  washed  out 
with  a  solution  of  bichloride  of  mercury,  and  packed  with  iodoform 
gauze,  which  has  to  be  renewed  every  few  days  till  the  cavity  is  filled 
by  granulations.  Finally,  the  whole  gland  may  be  extirpated,  and 
union  by  first  intention  attempted  by  means  of  sutures.  It  may  be 
advisable  to  use  tier-sutures  of  catgut  (p.  221).  Pozzi1  facilitates 
the  extirpation  by  emptying  the  cyst  with  a  hydrocele  trocar,  and 
injecting  it  with  spermaceti  molten  at  a  low  temperature  and  hard- 
ened after  injection  by  the  application  of  ice.  Combined  with  injec- 
tion of  cocaine,  the  cold  serves  as  an  anesthetic. 

3.  Abscess. — With  or  without  preliminary  formation  of  a  cyst  the 
gland  may  suppurate  and  form  an  abscess.  The  left  gland  is  more 
frequently  affected.  The  process  is  accompanied  by  the  usual  signs 
of  inflammation — pain,  swelling,  redness,  heat,  and  considerable  sys- 
temic disturbance.  The  inguinal  glands  are  commonly  implicated. 
If  left  to  Nature's  sole  efforts,  it  breaks  on  the  inside  of  the  labium 
majus  in  one  or  more  places,  and  often  fistulous  tracks  remain. 
There  is  in  many  women  a  tendency  to  repetition  of  such  abscesses. 
The  pus  has  the  same  offensive  odor  as  abscesses  in  the  ischio-rectal 
fossa  or  near  the  fauces.  Gonococci  have  been  found  in  the  pus-cells. 

The  abscesses  may  leave  a  chronic  suppuration  of  the  gland,  or 
such  a  condition  may  develop  without  abscess.  There  is  then  little 
swelling  and  tenderness,  but  a  continual  discharge  of  a  purulent  fluid 
through  the  duct  of  the  gland.  This  suppuration  is  perhaps  always 
brought  on  by  gonorrhea,  and  continually  gives  rise  to  new  infection. 

Diagnosis. — Furuncles  are  situated  in  the  skin.  Phlegmonous  vul- 
viiis  has  not  the  distinct  limits  and  the  peculiar  situation  of  the 
abscess  of  the  gland.  A  stercoral  abscess  originates  nearer  the  anus. 

Treatment. — The  abscess  must  be  laid  open  by  a  long  incision  on  the 

1  Samuel  Pozzi,  "Trait4  de  Gyn£cologie  clinique  et  operatoire,"  Paris,  1890,  p. 
1032. 


DISEASES  OF  THE   VULVA.  291 

inner  side  of  the  labium  majus,  disinfected,  and  packed  with  iodoform 
gauze.  The  opening  may  conveniently  be  made  with  Paquelin's  cau- 
tery. If  there  is  frequent  recurrence  of  the  formation  of  such  abscesses 
or  a  chronic  suppuration,  it  is  best  to  extirpate  the  gland  in  toto.  It  is 
not  worth  while  trying  primary  union.  It  rarely  succeeds,  and  it  is 
better  to  pack  the  wound  with  iodoform  gauze.  The  extirpation  of 
the  gland  should  be  done  at  a  time  when  the  surrounding  tissue  is 
not  inflamed.  In  using  the  knife,  it  should  be  remembered  that  the 
gland  lies  close  up  to  the  vulvo-vaginal  bulb,  only  separated  from  it 
by  a  thin  fascia.  Wounding  the  bulb  might  give  rise  to  troublesome 
hemorrhage. 


CHAPTER  XVI. 
VENEREAL  DISEASES. 

VENEREAL  DISEASES  form  so  great  a  part  of  the  affections  that 
come  under  the  observation  of  the  gynecologist,  and  are  so  often  the 
cause  of  others  treated  by  him,  that  a  brief  re'sume  of  the  most  com- 
mon features  of  these  diseases  seems  desirable  in  a  work  of  this  kind. 

1.  Gonorrhea. — We  have  already  spoken  of  the  gonorrheal  vulvitis 
(p.  267).     It  has  so  great  a  tendency  to  implicate  the  urethra  that 
the  presence  or  absence  of  urethritis  has  a  certain  diagnostic  import- 
ance.    It  enters  often  the  duct  of  the  vulvo-vaginal  gland,  and  may 
cause  catarrh,  cyst,  abscess,  or  chronic  inflammation  of  the  gland.     In 
most  cases  the  inflammation  spreads  up  the  vagina  to  the  vaginal 
portion  of  the  uterus.     Fortunately,  it  generally  stops  here,  but  some- 
times it  invades  the  cavity  of  the  uterus,  causing  purulent  endome- 
tritis;  attacks  the  lining  membrane  of  the  tube,  producing  salpingitis 
and  pyosalpinx;  and  reaches  finally  the  ovary  and  the  peritoneal 
cavity,  giving  rise  to  oophoritis  and  peritonitis — conditions  that  may 
make  the  patient  an  invalid  for  life  or  necessitate  capital  operations. 

It  will,  therefore,  be  seen  that  a  gonorrhea  in  the  female  is  a  much 
more  serious  disease  than  the  corresponding  affection  in  the  male. 

If  limited  to  easily  accessible  parts,  the  disease  may  be  cured  in  a 
few  weeks ;  but  if  it  invades  deeper  parts,  especially  the  vulvo-vaginal 
glands  or  the  tubes,  it  may  become  chronic  and  persist  indefinitely 
until  the  focus  of  infection  is  removed. 

In  regard  to  treatment  of  the  external  genitals,  sufficient  has  been 
said  in  speaking  of  vulvitis  (p.  268)  and  the  diseases  of  the  vulvo- 
vaginal  glands.  As  to  that  of  the  internal  genitals,  the  reader  is 
referred  to  later  chapters,  where  the  diseases  of  the  vagina,  uterus, 
tubes,  and  ovaries  are  discussed. 

2.  Chancroid. — Chancroid,  or  soft  chancre,  is  frequently  found  on 


292  DISEASES  OF  WOMEN. 

the  vulva  and  surrounding  parts  of  the  skin,  while  it  is  rare  on  the 
walls  of  the  vagina,  but  appears  more  frequently  on  the  vaginal  por- 
tion of  the  uterus. 

Whether  inoculation  takes  place  at  once  in  several  places,  or  that 
from  the  first  affected  part  the  poison  is  carried  to  other  points,  as  a 
matter  of  fact  chancroids  are  commonly  multiple  in  women.  A 
chancroid  is  a  contagious,  inflammatory,  destructive  ulcer.  On  the 
mucous  membrane  it  begins  as  a  minute  yellow  spot  surrounded  by 
a  red  ring.  Soon  the  epithelium  over  the  spot  is  lifted  so  as  to  form 
a  pustule,  and  is  then  carried  off,  leaving  an  ulcer.  On  the  skin  the 
ulcer  may  form  without  the  intervention  of  a  pustule.  The  ulcer  is 
usually  round  or  oval,  but  may  become  irregular  by  extension  or  the 
confluence  of  several  single  ulcers.  The  edges  are  cut  perpendicularly, 
minutely  jagged,  and  more  or  less  undermined.  The  ulcer  is  sur- 
rounded by  a  red  halo  or  areola.  The  floor  is  uneven  and  covered 
with  a  yellow  film  of  debris.  The  secretion  is  in  the  beginning  rather 
abundant,  and  has  a  peculiar,  very  penetrant,  and  nauseating  odor. 
It  is  thinner  than  that  of  gonorrhea,  and  has  a  brownish  color  from 
admixed  blood.  Under  the  microscope  are  seen  pus-corpuscles,  red 
blood-corpuscles,  and  detritus,  or  broken-down  tissue. 

If  properly  treated,  chancroids  heal  in  a  few  weeks.  If  neglected, 
they  persist  for  many  months,  go  on  forming  new  ulcers  indefinitely, 
and  may  cause  great  destruction,  and  even,  in  rare  cases,  become  fatal* 

Complications  are  less  common  than  in  the  male.  It  is  even  rare 
to  see  an  inguinal  gland  become  inflamed  and  form  an  abscess. 
Occasionally,  however,  in  unhealthy  and  weak  subjects  phagedena 
may  set  in,  and  extend  far  over  the  nates  and  the  abdominal  wall. 

Peculiar  to  women  is  what  is  called  the  chronic  chancroid.  It 
begins  as  an  acute  chancroid,  but  loses  its  infecting  power,  and  causes 
often  hyperplasia  of  the  surrounding  parts.  (See  Lupus,  p.  285.) 
It  is  entertained  by  lack  of  cleanliness,  gonorrheal  and  leucorrheal 
discharges,  and  drink.  The  term  is  even  used  in  speaking  of  "  any 
good-sized  intractable  ulcer  "  of  the  vulva,  although  there  is  no  proof 
that  it  began  as  a  typical  acute  chancroid.1  For  years  women  affected 
with  such  ulcers  and  hyperplastic  formations  may  feel  well,  but  in 
the  course  of  time  the  ulcers  may  perforate  the  urethra,  the  bladder, 
and  the  rectum,  or  burrow  far  away  under  the  skin,  forming  large 
cavities,  which  may  open  by  fistulous  tracts  about  the  buttocks  or  the 
thighs.  Hemorrhages  of  greater  or  less  severity  may  take  place,  or 
erysipelas  start  from  the  genitals.  In  the  course  of  years  such  women 
may  fall  a  prey  to  pulmonary  phthisis  or  succumb  to  kidney  and 
liver  complaints.  Some  are  subject  to  chronic  diarrhea  and  dys- 
entery, or  are  finally  carried  off  by  pyemic  infection. 

Treatment. — The  acute  chancroid  should  be  destroyed  with  undi- 
1  K.  W.  Taylor,  N.  Y.  Med.  Jour.,  Jan.  4,  1890.  ' 


DISEASES  OF  THE   VULVA.  293 

luted  carbolic  acid,  nitric  acid,  or  Paquelin's  ther mo-cautery,  under 
local  anesthesia  with  cocaine.  The  affected  parts  must  be  kept  from 
contact  with  others  by  covering  them  with  pieces  of  absorbent  lint  or 
pledgets  of  absorbent  cotton  dipped  in  some  mild  solution — e.  g., 

fy.  Acidi  carbolici,  TTLXX  to  xl ; 

Glyceriui,  3ss ; 

Aquse,  ad  siv, 

or  smeared  with  the  iodoform -balsam  of  Peru  ointment  (p.  178). 
Vaginal  injection  with  bicarbonate  of  soda  or  borax,  followed  by  cor- 
rosive sublimate  (1  :  5000),  should  be  used  several  times  daily.  The 
substance  that  makes  the  ulcers  granulate  fastest  after  cauterization 
is  iodoform,  which  is  powdered  on  them  daily. 

As  a  colorless  and  odorless  substance,  salicylic  acid  mixed  with  4 
or  8  parts  of  subnitrate  of  bismuth  is  often  preferred,  and  may  answer 
a  good  purpose.  When  granulation  is  started,  it  may  be  hastened  by 
dressing  with  sol.  argenti  nitrat.  (gr.  j— §iv),  liq.  sodii  chlorinat. 
(jjij— ,3iv),  sol.  acidi  borici  satur.,  or  vinum  aromat.  diluted  with  4 
parts  of  water. 

If  a  chancroid  becomes  phagedenic,  the  constitution  of  the  patient 
must  be  improved  with  nourishing  diet,  stimulants,  and  tonics.  The 
unhealthy  tissue  may  be  removed  with  the  curette,  or  by  touching  it 
with  nitric  acid,  bromine-glycerin  (1  :  3),  or  Paquelin's  cautery.  After 
that  the  patient  should  use  hot  sitz-baths  (98°-102°  F.)  from  eight 
to  twelve  hours  daily. 

Bubos  are  painted  with  tincture  of  iodine.  If  they  suppurate,  they 
must  be  opened  in  their  full  length,  washed  out  with  disinfectants, 
packed  with  iodoform  gauze,  covered  with  a  compress  of  the  same 
material,  and  over  that  a  peat-bag  or  a  layer  of  moss  impregnated 
with  corrosive  sublimate  or  a  thick  layer  of  plain  cotton-wool. 
Pressure  by  means  of  a  spica  promotes  recovery  in  a  marked  degree. 
This  dressing  is  changed  daily. 

The  curette  may  be  used  to  remove  broken-down  glandular  tissue. 
When  the  cavity  granulates,  the  iodoform  ointment  or  the  pure  bal- 
sam of  Peru  is  used  for  dressing.  An  occasional  painting  with 
nitrate-of-silver  solution  (gr.  x  or  xx  to  3j)  hastens  the  process  of 
healing.  Pure  boracic  acid  is  also  excellent  for  dressing. 

3.  Syphilis. — The  initial  lesion  of  syphilis,  the  hard  chancre,  is 
often  not  to  be  found  on  the  genitals  of  women.  The  cause  of  this 
is  twofold :  First,  the  lesion  by  which  inoculation  of  the  syphilitic 
virus  takes  place  is  much  more  frequently  than  in  man  situated  on 
other  parts  of  the  body,  especially  the'  breast  and  the  lips.  This  is 
so  in  25  per  cent,  of  all  cases.  Secondly,  the  characteristic  induration 
of  the  true  infecting  chancre  is  often  missing.  The  syphilitic  neo- 
plasm is  there,  but  the  new-formed  cells  are  so  few  in  number  or  so 


294  DISEASES  OF  WOMEN. 

loosely  patched  together  that  the  characteristic  sclerosis  is  not  devel- 
oped. When,  furthermore,  we  take  into  consideration  that  the  female 
genitals,  on  account  of  their  shape,  are  much  less  open  to  inspection, 
even  to  the  patient  herself,  and  that  the  initial  lesion  may  heal  with- 
out leaving  any  visible  cicatrix,  it  will  be  understood  that  sometimes 
it  is  entirely  overlooked,  and  that  secondary  and  tertiary  symptoms 
may  appear  although  there  is  no  history  of  any  sores  on  the  genitals 
or  elsewhere,  and  no  evidence  can  be  found  of  their  previous  existence. 

The  first  period  of  incubation — that  is,  the  time  elapsing  between 
the  infection  and  the  appearance  of  the  hard  chancre — varies  in 
length  from  ten  to  seventy  days.  The  second  period  of  incubation — 
that  is  to  say,  the  time  from  the  appearance  of  the  chancre  to  that  of 
general  or  constitutional  symptoms  of  syphilis — occupies  from  forty 
to  seventy  days.  The  first  and  second  periods  of  incubation  together 
commonly  last  from  sixty  to  ninety  days.  During  the  second  period 
of  incubation  the  primary  lesion  acquires  greater  development  and 
the  inguinal  glands  become  swollen.  This  happens  from  five  to  ten 
days  after  the  appearance  of  the  chancre. 

The  syphilitic  poison  may  come  from  a  hard  chancre,  from  sec- 
ondary syphilitic  manifestations,  especially  mucous  patches,  or  be 
inoculated  with  blood  or  lymph. 

Any  part  of  the  vulva  and  its  surroundings  may  be  the  seat  of  the 
initial  lesion.  Most  commonly  it  is  found  on  the  labia  majora.  It 
is  sometimes  developed  on  the  cervix  uteri,  but  very  rarely  on  the 
walls  of  the  vagina. 

It  begins  as  a  superficial,  flat,  reddish  erosion,  which  soon  forms  a 
round  or  oval  flat  ulcer  of  dark  red  or  grayish  color,  with  smooth 
floor,  sparse  serous  secretion,  and  sometimes  a  more  or  less  hard  base. 
Often  an  infection  with  pyogenic  microbes  takes  place  simultaneously 
with  the  introduction  of  the  syphilitic  virus.  Then  the  secretion  of 
the  ulcer  becomes  more  purulent  and  the  floor  shows  local  gangrene. 
Exceptionally,  a  syphilitic  lesion  may  become  phagedenic.  If  a  double 
infection  with  syphilitic  virus  and  that  from  a  chancroid  takes  place 
simultaneously,  the  chancroid  is  first  developed,  and  changes  in  the 
course  of  time  its  appearance,  so  as  to  form  a  syphilitic  chancre 
(mixed  chancre). 

The  primary  lesion  is  commonly  single,  but  may  be  multiple  and 
may  be  combined  with  soft  chancres.  It  stays  a  variable  length  of 
time — even  several  months — but,  as  a  rule,  heals  readily,  and  may  dis- 
appear without  leaving  any  trace. 

The  inguinal  glands  form  a  cluster  of  indolent  swellings.  But 
where  there  is  a  suppurating  ulcer,  there  may  also  occur  inflammation 
and  abscess  of  the  inguinal  glands. 

Diagnosis. — Since  the  characteristic  induration  is  often  absent,  the 
diagnosis  of  the  primary  lesion  becomes  more  difficult  in  women  than 


DISEASES  OF  THE   VULVA.  295 

in  men.  The  following  points '  may  occasionally  be  found  useful  in 
making  a  differential  diagnosis :  In  herpes  progenitalis  the  inguinal 
glands  are  not  affected ;  the  base  is  soft ;  the  contour  is  polycyclic — 
that  is  to  say,  composed  of  regular  segments  of  small  circles  that  have 
been  blended  together ;  the  development  is  more  limited,  and  the  exco- 
riation heals  rapidly ;  the  affection  itches ;  and,  as  a  rule,  the  erosions 
are  multiple.  Chancroid  is  nearly  always  multiple.  It  forms  a 
deep  ulcer  of  yellowish  red  color,  with  perpendicular,  undermined 
edges,  uneven,  worm-eaten  floor,  soft  base,  and  abundant  purulent 
secretion ;  the  pus,  when  inoculated  on  the  patient,  forms  another 
chancroid ;  the  inguinal  glands  are  not  swollen  or  form  an  inflamma- 
tory bubo  which  may  produce  an  abscess  with  simple  or  chancroidal 
pus. 

Treatment. — The  primary  lesion  being  a  symptom  of  an  infection 
that  already  has  taken  place,  cauterization  is  useless,  and  objectionable 
on  account  of  the  inflammation  it  brings  about  in  the  circumference. 
The  genitals  should  be  kept  clean  and  the  ulcer  dressed  with  absorb- 
ent lint  or  cotton  soaked  in  bichloride-of-mercury  solution  (1  :  1000 
or  2000)  or  one  of  the  other  solutions  mentioned  above  in  speaking 
of  chancroid,  the  dressing  to  be  changed  every  two  hours.  If  the 
ulcer  suppurates  or  is  the  seat  of  molecular  disintegration,  it  should 
be  dusted  with  iodoform  or  equal  parts  of  calomel  and  bismuth,  or 
dressed  with  the  lotio  hydrargyri  flava  containing  corrosive  sublimate, 
or  lotio  hydrargyri  nigra,  made  with  calomel.  In  cases  of  consider- 
able induration  blue  ointment  may  be  rubbed  on  the  seat  of  the  swell- 
ing and  applied  to  it  spread  on  lint. 

If  the  sore  is  covered  with  a  pultaceous  mass,  cauterization  with 
carbolic  acid,  nitric  acid,  or  chloride  of  zinc,  dissolved  in  equal  parts 
of  distilled  water  is  indicated.  In  regard  to  phagedena  the  treatment 
is  the  same  as  described  under  Chancroid,  combined  with  general 
antisyphilitic  treatment. 

Secondary  Syphilis. — The  vulva  is  the  seat  of  predilection  of  mucous 
patches  in  women.  In  the  vagina  they  are  exceedingly  rare,  but  appear 
more  frequently  on  the  cervical  portion  of  the  uterus.  They  are 
often  found  symmetrically  on  both  sides  of  the  vulva,  not  on  account 
of  auto-inoculation,  but  because  the  irritation  is  the  same.  They 
form  round  or  oval  spots,  with  a  tendency  to  coalesce.  They  are  a 
little  elevated  above  the  mucous  membrane,  and  have  well-defined 
steep  borders.  The  color  is  rosy  or  grayish  red.  They  have  a  some- 
what granular  surface,  and  secrete  a  malodorous  serous  fluid.  They 
are  quite  amenable  to  treatment,  but  may,  if  neglected,  form  large 
cauliflower-shaped  tumors  like  vegetations,  and  may,  like  them,  be- 
come gangrenous.  On  the  vaginal  portion  mucous  patches  appear  as 

1  A.  Fournier,  Lemons  sur  la  Syphilis  etudiee  particuliZrement  chez  la  Femme,  Paris, 
1873,  pp.  261,  281. 


296  DISEASES  OF  WOMEN. 

small  red  erosions,  or,  more  rarely,  as  superficial  ulcers.  Combined 
with  general  mercurial  treatment,  mild  cauterization  with  nitrate  of 
silver  makes  mucous  patches  soon  shrivel  and  disappear,  without 
leaving  any  cicatrix. 

Tertiary  Syphilis. — Gummous  nodes  are  not  rare  in  the  labia 
majora.  They  form  first  deep-seated  globular  tumors,  which  may 
break  and  leave  ulcers.  These  latter  may  be  difficult  to  diagnosticate 
from  other  ulcers  in  the  same  locality,  but  are  distinguished  from 
them  by  being  rapidly  healed  by  the  internal  use  of  potassium  iodide. 
At  the  same  time,  the  usual  precautions  in  regard  to  cleanliness  and 
protection  that  have  been  detailed  above  should  be  observed. 


CHAPTER   XVII. 
PROLAPSE  OF  THE  URETHRA. 

To  describe  all  the  diseases  of  the  urethra  and  the  bladder  would 
require  more  space  than  we  can  afford,  and  they  do  not  strictly  be- 
long to  those  organs  the  diseases  of  which  form  the  subject  of  this 
treatise.  It  might,  however,  be  advisable  to  say  a  few  words  about 
prolapse  of  the  urethra,  on  account  of  the  diagnosis  and  the  treat- 
ment. 

While  a  slight  eversion  of  the  mucous  membrane  of  the  urethra  is 
exceedingly  common,  especially  in  women  who  have  borne  children, 
the  extrusion  of  a  sufficiently  large  part  of  it  to  form  a  tumor  is  of 
rare  occurrence.  It  is  mostly  found  in  children,  old  people,  or  weak 
subjects.  It  is  caused  by  straining  during  micturition  or  defecation 
— e.  g.  when  a  stone  is  lodged  in  the  bladder  or  the  anus  is  the  seat 
of  a  fissure. 

The  disease  may  implicate  the  whole  circumference  of  the  urethra 
or  only  a  part  of  it,  most  commonly  the  lower.  In  the  first  case  the 
urethral  canal  is  found  in  the  centre  of  the  tumor ;  in  the  second,  it 
is  placed  excentrically. 

The  prolapse  gives  rise  to  or  increases  vesical  tenesmus  and  may 
produce  cystitis.  In  the  beginning  the  tumor  has  the  appearance  of 
the  normal  mucous  membrane,  but  later  it  becomes  darker  and  denser, 
and  is  sometimes  excoriated. 

Diagnosis. — When  the  prolapse  is  total,  the  presence  of  the  lumen 
of  the  canal  in  its  center  settles  at  once  the  diagnosis.  If  it  is  partial, 
it  may  be  taken  for  a  caruncle,  but  it  differs  from  the  latter  by  always 
having  a  broad  base  and  by  being  easily  reduced. 

Treatment. —  Simple  reduction  with  a  finger  or  sound,  followed  by 
the  use  of  a  cupped  bougie,  with  tannin  or  the  application  of  tincture 


DISEASES  OF  THE   VULVA.  297 

of  iodine,  rest  in  bed,  and  hot  vaginal  douches  and  affusions,  may  be 
tried.  If  they  do  not  succeed — which  can  only  be  expected  in  slight 
cases — operative  interference  is  called  for:  1.  The  tumor  may  be 
transfixed  at  its  base,  tied  in  two  halves,  and  cut  off.  2.  The  deeper 
part  of  the  mucous  membrane  may  be  secured  by  inserting  a  suture 
on  either  side,  and  uniting  the  two  edges  of  the  wound  with  a  continu- 
ous catgut  suture  after  cutting  the  redundant  tissue  off.  3.  Emmet's 
buttonhole-operation  may  be  performed  by  placing  the  patient  in 
Sims's  position,  introducing  his  speculum,  making  a  longitudinal 
incision  on  the  vaginal  wall  corresponding  to  the  course  of  the 
urethra  down  to  the  mucous  membrane  of  the  latter,  pulling  this 
through  the  opening  made,  introducing  some  transverse  sutures 
through  the  vaginal  and  urethral  mucous  membrane,  cutting  off  the 
redundant  tissue  over  the  sutures,  and  closing  the  latter. 

The  prolapsed  portion  may  also  be  cut  off  in  front  of  the  meatus 
with  galvano-  or  thermo-cautery,  but  then  steel  bougies  should  be 
introduced  during  and  after  the  healing  in  order  to  avoid  stenosis. 
The  cutting  operations  with  sutures  are  the  best. 


CHAPTER  XVIII. 

MASTURBATION. 

MASTURBATION  consists  in  the  production  of  venereal  orgasm  by 
means  of  the  hand,  the  tongue,  or  any  kind  of  foreign  body  on  one's 
self  or  another  person.  It  is  also  called  onanism,  but  not  correctly, 
for  a  closer  scrutiny  of  the  ninth  verse  of  the  thirty-eighth  chapter 
of  Genesis  will  show  that  Onan  had  sexual  intercourse  with  Tamar, 
but  deprived  her  of  his  semen  by  spilling  it  outside  of  her  body  (au 
act  called  withdrawal).  It  is  not  usual  to  treat  of  this  subject  in 
works  on  gyuecology,  but  since  the  thing  exists,  since  it  appears  in 
innocent  childhood,  since  it  produces  certain  symptoms,  since  it  may 
be  the  cause  of  the  most  serious  diseases,  since  the  physician  called  as 
expert  in  a  suit  for  rape  may  be  able  to  exonerate  an  innocent  man 
by  knowing  the  effects  of  masturbation, — it  is,  in  my  opinion,  proper 
to  give  some  information  about  it  here. 

Masturbation  may  be  indulged  in  by  infants  of  either  sex  who 
have  no  idea  what  they  are  doing.1  They  may  either  be  taught  the 
vice  by  unscrupulous  nurses  in  order  to  make  them  quiet,  or  they 
may  accidentally  find  out  that  certain  movements  produce  a  pleasur- 

1  A.  Jacobi,  "  On  Masturbation  and  Hysteria  in  Young  Children,"  Amer.  Jour.  Obst., 
vol.  viii.  No.  4,  1875,  and  vol.  ix.  No.  2,  1876. 


298  DISEASES  OF  WOMEN. 

able  sensation.  In  older  female  children  I  do  not  believe  the  vice  is 
so  common  as  among  boys,  but  later  in  life  it  is  probably  much  more 
so  in  women  than  in  men.  This  cannot  be  explained  merely  by  the 
greater  facilities  offered  the  male  sex  for  normal  satisfaction  of  the 
sexual  instinct  without  running  the  risk  of  having  offspring.  There 
are  several  reasons  for  it,  one  of  which  is  the  less  degree  of  orgasm 
felt  by  women  during  normal  sexual  intercourse  (p.  121).  This,  at 
least,  would  seem  to  explain  the  fact  that  many  married  women  are 
given  to  this  vice — a  thing  that  certainly  is  exceedingly  rare  in  the 
male  sex. 

The  most  common  form  of  masturbation  in  women  consists  in 
titillation  of  the  clitoris,  be  this  executed  by  the  person's  own  hand 
or  that  of  another,  or  by  the  tongue  of  another  human  being  or  of  a 
dog,  or  by  any  other  object.  Less  frequently  the  finger  or  other  more 
or  less  penis-shaped  bodies,  such  as  roots  or  needle-cases,  are  intro- 
duced into  the  vagina. 

1.  Masturbation  in  Infancy. — Masturbation   in   early    childhood 
being  in  many  respects  peculiar,  we  must  consider  its  symptoms  and 
treatment  separately.     In  some  cases  there  may  be  local  changes,  such 
as  redness  of  the  entrance  of  the  vagina,  moisture  of  the  labia  and 
vagina  from  over-secretion  of  the  glands  of  Bartholin  and  the  smaller 
muciparous  glands  of  the  vulva.     But  these  cases  are  by  no  means 
frequent.     Of  much  greater  importance  are  certain  other   changes 
observable  in  the  child,  such  as  the  occurrence  of  sudden  redness  in 
the  face,  followed  by  paleness,  twitching  of  the  muscles  about  the 
eyes,  hurried  breathing,  and  a  deep  sigh.     These  spells  come  on  when 
the  child  is  sitting  on  the  floor,  often  rocking  to  and  fro  or  pressing 
the  fists  into  the  iliac  fossa?  or  against  the  genitals.     These  attacks 
lead  to  anemia,  bloatedness,  and  irritability  of  temper. 

Treatment. — First  of  all,  infants  and  their  nurses  should  be  care- 
fully watched.  If  there  are  pin-worms  in  the  rectum,  they  should  be 
removed  (p.  273).  If  the  composition  of  the  urine  is  abnormal,  it 
should  be  remedied  by  proper  medicine,  especially  alkalies  and  ano- 
dynes. The  couch  should  be  hard,  the  cover  not  warmer  than  what 
is  necessary  to  protect  the  child.  It  should  not  have  too  rich  food : 
large  quantities  of  meat,  eggs,  spices,  salt,  and  beer  are  injurious. 
Drugs  that  irritate  the  uropoietic  system,  such  as  cantharides  or  nitrate 
or  chlorate  of  potash,  should  be  avoided  or  handled  with  care. 
During  the  act  the  child  should  be  taken  up,  her  thighs  separated, 
her  hands  removed  from  her  abdomen,  and  her  mind  diverted.  The 
anemia  and  nervousness  should  be  treated  with  strychnine,  iron,  and 
arsenic. 

2.  Masturbation   in    Older    Children    and  Adults. — Symptoms. — 
The  frequently  repeated  act  of  self-abuse  or  masturbation  with  another 
person  leaves  certain  local  changes  in  the  genitals  which  it  is  useful 


DISEASES  OF  THE  VULVA.  299 

to  know.  It  is  true  that  uot  one  of  them  is  pathognomonic,  but  the 
presence  of  several  of  them  must,  to  say  the  least,  awaken  suspicion 
and  may  help  to  find  out  the  truth.  The  clitoris  is  both  thickened 
and  elongated.  The  glans  is  red  and  protrudes  beyond  the  pre- 
puce. The  prepuce  is  lax,  red,  and  thickened.  The  labia  minora 
are  elongated,  flaccid,  wrinkled,  of  brown,  gray,  or  slate-like  color, 
with  black  irregular  spots  due  to  the  deposit  of  pigment  in  the 
deep  layer  of  the  epidermis.  This  change  in  size  and  aspect  is 
often  unilateral.  On  the  inner  surface  of  the  labia  minora  is  found 
a  series  of  minute  white  or  yellow  spots  like  insect  eggs,  formed  by 
hypertrophied  glands.  Sometimes  the  labia  majora  are  likewise 
enlarged,  flaccid,  and  wrinkled.  The  hymen  may  be  torn,  but  is 
more  commonly  not  so,  but  so  lax  that  the  finger  enters  without 
meeting  any  resistance.  The  vaginal  entrance  and  the  rima  pudendi 
may  be  gaping.  Often  leucorrhea  and  other  signs  of  vulvitis  (p.  266) 
are  present.  The  vulvo-vaginal  glands  may  be  inflamed.  The  vulva 
may  show  fresh  scratches  or  old  cicatrices,  and  the  clitoris  has  been 
found  wounded  and  nearly  bitten  off — conditions  which  may  cause 
hemorrhage  or  leave  wounds  slow  to  heal. 

As  to  the  general  health,  women  seem  to  have  a  greater  power  of 
resistance  in  regard  to  the  effects  of  masturbation  than  men.  There 
are,  indeed,  women  who  are  confirmed  masturbators,  and  yet  enjoy 
excellent  health,  but,  as  a  rule,  they  pay  as  well  as  the  other  sex  for 
their  illicit  pleasure  by  pain,  ache,  and  ailment.  The  works  of 
specialists  in  this  line  must,  however,  be  read  with  more  criticism 
than  their  authors  usually  show  in  writing  them,  nearly  every  known 
disease,  inclusive  of  pneumonia,  that  ever  has  been  observed  in  a 
woman  addicted  to  masturbation  having  been  put  on  the  list  of  the 
consequences  of  the  habit.  Certain  diseases  are,  nevertheless,  found 
so  often  in  masturbators,  and  the  connection  between  them  and  the 
vice  is  so  easy  to  understand,  that  we  do  not  hesitate  in  looking  upon 
them  as  cause  and  effect.  We  find  inflammation  of  any  part  of  the 
genitals,  periuterine  hematocele,  and  pelvic  peritonitis — conditions 
which  all  stand  in  a  natural  relation  to  the  irritation  and  frequent 
congestion  of  the  genitals  and  pelvic  organs. 

The  nervous  system  suffers  more  than  any  other,  and  in  all  its 
functions :  the  hands  are  apt  to  tremble  or  the  gait  may  become 
unsteady ;  the  perception  of  all  the  senses  loses  more  or  less  of  its 
acuteness ;  the  memory  weakens ;  interest  in  all  intellectual  matters 
diminishes;  wandering  pains  of  neuralgic  origin  are  quite  common  ; 
hysteria,  epilepsy,  chorea,  paralysis,  and  insanity  may  be  developed, 
but  it  may  be  hard  to  decide  whether  the  masturbation  was  the  cause 
of  the  insanity  or  if  the  lurking  insanity  impelled  to  masturbation. 
I  have  seen  a  peculiar  nemesis  in  a  young  lady  who  was  accustomed 
to  discount  the  pleasures  of  married  life,  and  Avho,  when  she  married 


300  DISEASES  OF  WOMEN. 

a  strong  young  man,  failed  to  feel  the  slightest  satisfaction  in  the 
normal  relation  between  man  and  wife. 

Nutrition  suffers,  as  a  rule,  soon.  The  patient  loses  flesh,  the  face 
becomes  pale,  dark  rings  appear  under  the  eyes,  the  appetite  is  poor, 
the  digestion  difficult,  and  the  bowels  constipated.  It  is  said  that 
fresh  cicatrices  are  liable  to  break  up  and  ulcerate. 

The  neighboring  organs  are  apt  to  suffer.  Sometimes  the  sphincter 
muscles  of  the  urethra  become  paralyzed.  Cystitis  may  be  caused  by 
the  irritation,  and  the  inflammation  may  spread  up  to  the  kidneys. 
Stone  may  form  around  foreign  bodies  used  for  masturbation  which 
are  lost  hold  of  and  enter  the  bladder — e.  g.  a  hair  pin.  The  sphinc- 
ter of  the  anus  may  become  relaxed  and  give  rise  to  a  prolapse  of  the 
rectum. 

Masturbation  entails  often  sterility  or  abortion,  and  if  children  are 
carried  to  term,  they  are  apt  to  be  puny,  neurotic,  and  weak. 

Treatment. — The  treatment  must  be  moral  as  well  as  physical. 
The  physician  must  use  every  effort  to  impress  upon  the  mind  of  the 
patient  the  bad  consequences  of  her  vice.  Any  palpable  cause  of 
irritation,  such  as  pin-worms,  accumulated  smegma,  bladder  catarrh, 
calculi,  or  hemorrhoids,  must  be  removed.  The  food  should  be 
bland ;  alcoholic  beverages  and  spicy  dishes  should  be  forbidden. 
The  body  should  be  tired  with  manual  work,  gymnastics,  or  walking ; 
the  mind  occupied  by  attractive  subjects.  Cold  baths  should  be  used 
in  the  morning,  but  not  in  the  evening  on  account  of  the  following 
reaction.  The  patient  should  lie  on  a  hard  mattress,  lightly  covered, 
with  the  arms  above  the  cover,  and  in  a  cool  room.  The  nervous 
system  must  be  quieted  with  camphor,  lupulin,  the  bromides  of 
ammonium,  potassium,  and  sodium,  or  monobromide  of  camphor. 

In  the  worst  cases  clitoridectomy  is  indicated,  and  has  effected  some 
remarkable  cures.  It  is  a  simple  operation,  but,  as  it  has  led  to  sep- 
tic peritonitis  and  death,  it  ought  to  be  performed  with  antiseptic 
precautions.  It  is  only  the  glans  and  body  that  are  removed.  This 
may  be  done  with  a  bistoury  or  curved  scissors  and  sutures  applied, 
or  one  may  use  the  thermo-  or  galvano-cautery.  There  is  no  reason 
why  this  little  bit  of  flesh  should  not  be  removed,  and,  as  it  certainly  is 
the  most  excitable  part  of  the  genitals,  it  is  rational  to  do  so  in  cases 
of  abnormal  excitability  irresistibly  leading  to  masturbation,  ruining 
the  health  of  the  patient,  depriving  her  of  her  mental  faculties,  or 
driving  her  to  suicide. 


PART  II. 

DISEASES  OF  THE  PERINEUM. 


CHAPTER  I. 

INJURIES. 

HERE  we  only  have  to  deal  with  the  anal  part  of  the  perineal  re- 
gion, the  injuries  to  the  vulva  having  been  considered  above  (p.  265). 

For  convenience'  sake  we  will,  however,  simply  call  it  the  perineum. 
The  perineum  is  exposed  to  injuries  from  without  and  from  within. 

I.  Injuries  from   Without. — Contusions  and  contused,  punctured, 
incised,  or  torn  wounds,  involving  a  more  or  less  complete  laceration 
of  the  partition  between  the  genitals  and  the  rectum,  are  produced 
by  falling  down  on  the  upright  of  a  chair,  a  slat  of  a  fence,  a  pitch- 
fork, or  similar  pointed  object,  or  by  sliding  down  the  balusters  of  a 
staircase  against  the  boss  of  the  newel-post.     Similar  lesions  are  some- 
times caused  by  the  horns  of  cattle  or  result  from  rape  where  there  is 
a  marked  disproportion  in  the  size  of  the  organs  that  come  in  contact. 

Treatment. — The  treatment  is  the  same  as  for  injuries  of  the  vulva. 

II.  Injuries  from  Within. — These  are  especially  caused  by  childbirth. 
Lacerations  of  the  perineum  may  be  recent  or  old,  complete  or 

incomplete,  open  or  submucous. 

A.  Recent  Lacerations  of  the  Perineum. — The  recent  laceration  of 
the  perineum  is  a  condition  that  is  considered  at  length  in  treatises 
on  obstetrics.1  Here  we  will  only  briefly  allude  to  a  few  points  which 
are  necessary  in  order  to  understand  the  old  lacerations,  or  have 
special  surgical  importance. 

As  we  have  seen  in  the  description  of  the  anatomy  of  these  parts 
(p.  43),  the  parturient  canal  is,  near  and  at  its  end,  limited  by  two 
comparatively  narrow  openings,  the  vaginal  entrance  and  the  rirna 
pudendi,  the  first  of  which  is  circular  from  the  beginning,  while  the 
second  becomes  so  when  distended  by  the  child  being  pushed  through 

1  More  detailed  information  on  the  subject  may  be  found  in  my  papers  on  "  The 
Obstetric  Treatment  of  the  Perineum,"  Amer.  Jour.  Obstet,  April,  1880,  vol.  xiii. 
p.  231,  et  seq. ;  and  on  "  So-called  Lacerations  of  the  Perineum,"  Med.  yews,  April, 
1891,  vol.  Iviii.  p.  454,  et  seq. 

301 


302  DISEASES  OF  WOMEN. 

it.  Of  these  rings  the  inner  one  is  again  the  narrower.  They  are 
the  seats  where  laceration  commonly  begins  during  childbirth,  and 
from  which  it  may  extend  more  or  less  into  the  neighboring  tissues. 
The  inner  ring,  the  vaginal  entrance,  being  the  narrower  of  the  two, 
suffers  more  constantly.  But  a  superficial  tear  here,  even  if  it  extend 
far  up  into  the  vagina,  is  of  little  importance.  A  deep  tear  of  this 
ring,  involving  the  levator  ani  muscle  with  its  two  fasciae  (pp.  94-95), 
is,  on  the  contrary,  a  fruitful  source  of  future  suffering.  The  tear  in 
the  levator  ani  muscle  is  usually  found  backward  and  outward  in  the 
direction  of  the  tuberosity  of  the  ischium,  probably  because  the  mus- 
cle gets  caught  between  this  point  and  the  head,  while  in  the  median 
line  the  rectum  furnishes  a  soft  pad  between  the  vagina  and  the  leva- 
tor  ani  muscle.  The  tear  is  much  more  common  on  the  right  than  on 
the  left  side,  which  is  probably  due  to  the  preponderance  of  the  left 
occipito-anterior  position,  the  occiput  escaping  from  the  genital  canal, 
while  the  forehead  is  pressed  against  the  posterior  wall  of  the  vagina. 

The  external  ring,  formed  by  the  extended  vulva,  escapes  often 
any  injury  through  childbirth,  so  that  even  the  thin  edge  of  the  four- 
chette  is  found  entire  in  women  who  have  borne  children.  It  may, 
however,  suffer  in  different  places.  The  most  common  is  a  tear  in 
the  median  line,  beginning  at  the  posterior  commissure,  from  which 
it  may  extend  down  to  and  into  the  anus  and  up  to  and  through  the 
vaginal  entrance.  More  rarely  this  perineal  rupture  begins  in  the 
center  of  the  perineum,  and  extends  forward  into  the  vulva,  forming 
a  similar  tear  as  if  it  had  started  from  the  fourchette ;  and  in  the 
rarest  of  all  cases  the  tear  in  the  perineum  becomes  sufficiently 
large  to  admit  of  the  passage  of  the  child  through  it  without  impli- 
cating the  rima  pudendi  or  the  anus  (centred  laceratioii). 

If  the  perineum  escapes  or  suffers  little,  the  injury  often  takes  the 
shape  of  superficial  tears  on  the  labia  majora  or  deeper  tears  in  the 
labia  minora  and  vestibule  near  the  clitoris  (p.  265). 

Nearly  all  tears  being  due  to  circular  expansion,  the  parts  separate 
laterally,  and  the  rents  have  a  longitudinal  direction  more  or  less 
parallel  to  the  axis  of  the  parturient  canal ;  but  if  the  severed  halves 
of  the  perineum  do  not  unite  by  first  intention,  they  heal  separately, 
each  forming  one-half  of  a  cicatrice,  in  which  way  cicatrices  with  a 
transverse  direction  are  formed.  This  has  given  rise  to  the  erroneous 
conception  that  the  fresh  tear  also  had  been  transverse,  which  it 
hardly  ever  is. 

Sometimes  nature  can  effect  complete  agglutination  and  coalescence 
by  first  intention  of  any  tear.  I  have  myself  seen  this  in  incomplete 
laceration  where  the  whole  periueal  body  was  severed  to  the  rectum, 
and  I  have  heard  of  the  same  lucky  result  in  cases  of  complete  lace- 
ration, in  which  nothing  was  done  except  to  tie  the  patient's  knees 
together.  But  such  a  process  is  of  so  extremely  rare  occurrence  that 


DISEASES  OF  THE  PERINEUM.  303 

it  is  foolhardiness  to  wait  for  it.  In  the  great  majority  of  cases  the 
natural  healing  is  altogether  insufficient.  Au  incomplete  tear  in  the 
median  line  will  heal  together  a  little  by  granulation  at  the  bottom 
of  the  angle;  the  remainder  will  only  heal  over  and  form  a  con- 
tracted transverse  scar.  A  complete  tear  will  leave  the  anal  ring 
broken :  the  sphincter  retracts,  its  ends  being  plainly  marked  by  a 
little  pit  of  the  size  of  a  large  pea  on  either  side ;  where  the  perineal 
body  should  be  is  seen  a  V-shaped  cleft ;  the  mucous  membrane  of 
the  rectum  rolls  out,  forming  a  little  red,  soft,  puckered  cushion  at 
the  posterior  circumference  of  the  anal  opening ;  and  the  patient  has 
no  control  over  flatus  and  feces,  which  escape  involuntarily  and  make 
the  poor  woman  an  object  of  disgust  to  herself  and  others. 

A  tear  involving  the  levator  ani  and  the  sinewy  structures  at  the 
vaginal  entrance  weakens  the  support  of  the  pelvic  structures  above. 
As  soon  as  she  gets  up  the  patient  complains  of  a  disagreeable  feeling 
of  looseness  and  bearing-down.  In  course  of  time  the  vaginal 
mucous  membrane  bulges  out  in  front  and  behind,  the  bladder  sinks 
down,  the  uterus  is  first  retroverted,  then  retroflexed,  then  it  descends, 
and  may  finally  hang  between  the  legs.  The  strain  on  the  utero- 
sacral  and  broad  ligaments  causes  pain  and  backache.  The  vagina  is 
inverted,  and  becomes  unfit  for  one  of  its  purposes.  Exposed  to 
friction  against  the  clothes,  the  vaginal  portion  of  the  uterus  becomes 
the  seat  of  a  deep  ulceration. 

Treatment. — Fresh  tears  should  be  united  immediately  after  the 
termination  of  childbirth  (primary  operation). 

Rupture  of  the  Outer  Ring. — If  the  tear  begins  at  the  posterior 
commissure  and  extends  more  or  less  far  toward  the 
anus  without  implicating  it  (incomplete  laceration),  and         FIG.  204. 
is  not  much  over  half  an  inch  high  (up  toward  the 
vagina),  this  may  in  most  cases  be  done  more  easily 
and  speedily,  and  with  much  less  pain,  by  means  of 
serrefines  (Fig.  204) — fine  self-holding  clamps  working 
on  the  principle  of  clothes-pins.     These  little  instru- 
ments are  applied,  from  one  to  three  in  number,  by 
placing  the  patient  on  her  left  side,  lifting  the  torn 
perineum  between  the  thumb  and  index-finger,  and  em- 
bracing it  with  the  legs  of  the  serrefine.     The  first  is 
placed  half  an  inch  from  the  end  of  the  tear,  the  fol- 
lowing with  half  an  inch  interval,  and  the  last  at  the 
anterior  end  of  the  tear.     Good  serrefines  should  have  so 
little  spring-force  that  the  obstetrician  can  put  them  on  the  web 
between  his  own  thumb  and  index-finger  without  feeling  pain,  and 
the  legs  must  be  half  an  inch  long  beyond  the  crossing.1 

1  Most  serrefines  on  the  market  are  of  very  inferior  make,  but  Geo.  Tiemann  & 
Co.  keep  some  good  ones  under  my  name. 


304  DISEASES  OF  WOMEN. 

In  fat  women  the  perineum  cannot  be  folded  as  described,  and,  there- 
fore, the  serrefines  cannot  be  used,  and  recourse  must  be  had  to  sutures. 

Sutures  should  always  be  used  where  the  vaginal  entrance  is  torn. 
If  the  tear  extends  up  into  the  vagina,  separate  vaginal  sutures  should 
be  passed,  beginning  at  the  upper  end  and  going  down  as  far  as  the 
perineal  body.  It  may  be  done  with  catgut,  by  interrupted  or  con- 
tinuous suture.  For  the  perineal  body  silkworm  gut  is  the  best  mate- 
rial. As  a  rule,  three  sutures  are  needed  on  the  perineum  proper. 
The  patient  is  placed  across  the  bed,  with  the  buttocks  drawn  to 
the  edge;  the  knees  are  bent  and  held  by  assistants,  the  feet  are 
placed  each  on  a  chair ;  and  the  operator  sits  on  a  third  between  the 
two  or  kneels.  The  parts  are  irrigated  with  a  disinfectant  fluid,  pref- 
erably creolin ;  a  large  cotton  tampon  with  an  attached  thread  is 
pushed  up  into  the  vagina  above  the  tear,  in  order  to  keep  blood 
away  from  the  field  of  operation.  Shreds  that  hang  loose  by  a  pedicle 
are  cut  off.  The  left  index-finger  is  introduced  into  the  rectum, 
while  the  assistants  stretch  the  torn  parts  symmetrically  from  side 
to  side.  A  rather  long  curved  needle  is  inserted  on  the  left  side,  a 
quarter  to  half  an  inch  outside  of  the  edge  of  the  tear  and  at  the  same 
distance  from  the  posterior  end  of  the  tear,  and  carried  underthe  torn 
surface  over  to  the  corresponding  point  on  the  other  side.  The  sec- 
ond suture  is  placed  about  half  an  inch  farther  forward,  parallel  to 
the  first,  and  is  likewise  entirely  imbedded.  It  embraces  often  the 
lower  end  of  the  mucous  membrane  above  the  tear.  The  third  and 
last  is  placed  a  little  below  the  posterior  commissure.  It  goes  only 
under  the  tear  in  the  left  labium  majus;  the  needle  emerges  on  the 
line  of  demarkation  between  this  torn  surface  and  the  mucous  mem- 
brane, is  again  entered  on  the  corresponding  point  on  the  right 
labium,  and  is  pushed  out  on  the  corresponding  point  of  the  skin. 
These  three  sutures  correspond  to  sutures  2,  4,  and  6  in  Fig.  206. 
Executed  with  proper  antiseptic  precautions,  this  operation  is  nearly 
always  successful. 

Before  closing  the  sutures  the  tampon  is  pulled  out ;  the  parts  are 
again  irrigated  and  dusted  with  iodoform.  Sly  perineal  pad,  or  anti- 
septic occlusion  dressing,  is  applied.  This  consists  of  (1)  a  piece  of 
absorbent  lint,  12  by  8  inches,  folded  twice  lengthwise,  so  as  to  be- 
come 3  inches  wide,  the  average  distance  from  one  genito-femoral 
sulcus  to  the  other ;  or  a  pledget  of  absorbent  cotton  of  somewhat 
larger  dimensions,  in  order  to  allow  for  shrinkage ;  (2)  a  piece  of 
gutta-percha  tissue,  9  inches  by  4 ;  (3)  a  large  pad  of  cotton  batting ; 
and  (4)  a  piece  of  unbleached  muslin  J  yard  square.  The  lint  or 
absorbent  cotton  is  wrung  out  of  some  antiseptic  fluid  and  carefully 
applied  over  the  vulva  and  the  anus.  The  gutta-percha  is  washed 
with  the  same  solution  and  placed  over  the  first  layer,  turning  the 
edges  forward  against  the  thighs.  The  outer  layer  of  cotton  batting 


DISEASES  OF  THE  PERINEUM.  305 

serves  only  to  give  bulk,  and  is  pressed  up  against  the  genitals  by  the 
muslin,  which  is  folded  like  a  cravat  5  inches  wide  and  fastened  to 
an  abdominal  bandage,  so-called  belly-binder,  in  front  and  behind. 
This  dressing  is  changed  three  or  four  times  in  twenty-four  hours,  or 
ofteuer  if  the  patient  has  a  movement  from  the  bowels  or  passes  her 
urine  in  the  mean  time.  Before  a  fresh  dressing  is  put  on  the  parts 
are  irrigated  externally  with  antiseptic  fluid,  the  patient  lying  on  a 
bed-pan.  No  vaginal  injection  is  given  ;  indeed,  the  genitals  are  not 
touched.1  The  knees  are  bound  loosely  together,  so  as  to  prevent 
wide  separation,  but  permit  limited  motion.  This  is  obtained  by 
surrounding  the  knees  with  a  wide  ring  of  muslin,  or  two  rings  with 
a  connecting  piece  like  eye-glasses,  which  are  prevented  from  sliding 
down  by  fastening  them  on  either  side  to  the  abdominal  binder  by 
means  of  a  long  narrow  strip  of  muslin  called  a  suspender.  The 
patient  is  allowed  to  urinate  herself  if  she  can,  and  the  bowels  are 
kept  open  by  means  of  a  mild  aperient. 

If  the  tear  extends  into  the  anus  and  more  or  less  far  up  the  rec- 
tum (complete  laceration),  the  immediate  operation  is  particularly 
indicated.  Even  if  only  partial  success  should  be  obtained,  and  a 
recto-vaginal  fistula  should  remain,  the  general  shape  of  the  parts  is 
retained  and  a  subsequent  operation  much  facilitated.  Under  these 
circumstances  it  is  best  to  make  a  triangular  suture,  one  row  along 
the  rectum,  one  along  the  vagina  and  vulva,  and  the  third  along  the 
cutaneous  surface  of  the  perineum.  The  first  two  should  be  deeper,  the 
last  more  superficial,  by  doing  which  the  formation  of  a  recto-vaginal 
fistula  above  the  perineal  body  is  best  obviated.  For  the  first  two 
rows  catgut  or  fine  silk  is  used ;  for  the  last  silkworm  gut  or  silver 
wire  is  preferable.  Special  care  should  be  taken  to  unite  the  ends  of 
the  sphincter  ani  muscle  on  the  principle  that  will  be  described  below 
in  speaking  of  Emmet's  operation  for  the  old  rent. 

If  the  parts  are  very  edematous,  the  edges  of  the  wound  will  gape 
when  the  swelling  subsides.  In  such  cases  it  is  advisable  to  wait 
twenty-four  hours  or  longer  before  operating,  or,  instead  of  tying  the 
suture,  half  a  dozen  perforated  shot  may  be  passed  over  the  free  ends, 
and  the  last  compressed  so  as  to  hold  the  suture  in  place.  When, 
then,  the  wound  later  is  found  to  gape,  the  last  shot  is  seized  with  a 
pair  of  forceps  and  pulled  upon,  carrying  the  suture  with  it,  until  the 
edges  are  again  in  contact,  when  the  next  shot  is  compressed  and  the 
first  cut  off.2  With  this  method  it  is  better  to  use  silver  wire,  the  ends 
of  which  may  be  turned  out,  so  as  to  give  a  firmer  hold  on  the  shot. 

Rupture  of  the  Inner  Ring. — Since  the  rupture  of  the  ring  forming 
the  vaginal  entrance  has  much  more  serious  consequences  than  that 

1  More  details  and  an  illustration  are  found  in  Garrigues'  Antiseptic  Midwifery,  p. 
27,  and  Amer.  Syst.  of  ObsL,  ii.  p.  351. 

3  J.  H.  Carstens,  Detroit,  Mich.,  Amer.  Jour.  ObsL,  1884,  vol.  xvii.  p.  241. 
20 


306 


DISEASES  OF  WOMEN. 


of  the  outer  ring,  except  when  the  latter  implicates  the  sphincter 
muscles  of  the  rectum,  medical  science  calls  for  its  immediate  treat- 
ment ;  but  in  most  cases  medical  diplomacy  and  other  considerations 
will  throw  their  weight  into  the  other  scale.  These  tears  are  mostly 
produced  by  an  unskilful  conduct  of  labor,  such  as  the  administration 
of  oxytocics,  manual  expulsion  of  the  child  by  pressure  on  the  fundus, 
a  precipitate  use  of  the  forceps,  or,  at  the  very  least,  the  omission  of 
means  to  ensure  a  slow  dilatation  of  the  vaginal  entrance  and  the 
vulva  during  the  birth  of  the  child ;  and  accoucheurs  who  will  commit 
such  faults  and  midwives  are  not  likely  to  examine  for  a  tear  that 
is  not  visible  on  the  skin,  and,  if  they  did,  would  hardly  be  compe- 
tent to  remedy  the  injury.  It  will  also  be  hard  for  the  general  prac- 


Recent  Tears  inside  the  Vagina  and  Suturing  (H.  Kelly) :  A,  vaginal  sutures  passed ;  B, 
sutures  tied  on  left  side;  C,  sutures  tied  on  both  sides  aiid  cutaneous  crown-suture  in 
place ;  D,  all  sutures  tied. 

titioner  to  persuade  the  patient  and  her  friends  to  allow  him  to  per- 
form a  protracted  operation  for  a  condition  the  importance  of  which 
is  doubtful  to  their  minds.  But  if  circumstances  permit  us  to  follow 
the  dictates  of  science,  the  injury  should  be  remedied  by  passing  a 
row  of  deep  sutures  from  above  downward  through  the  edges  of  the 
lateral  tear.  The  needle  should  be  carried  well  downward  in  the 
direction  of  the  vaginal  entrance  and  then  up  through  the  other  lip, 
lifting  up  the  pelvic  floor,  as  will  be  explained  in  describing  Emmet's 
operation  for  old  tears.  Catgut  is  the  best  material,  since  it  need  not 
be  removed.  A  single  cutaneous  suture  disposes  of  what  is  not  united 
by  the  preceding  sutures  (Fig.  205).  For  the  latter  silkworm  gut 
or  silver  wire  is  preferable. 

If  the  sphincter  ani  is  torn,  its  ends  should  be  brought  together 


DISEASES   OF  THE  PERINEUM.  307 

with  two  sutures — one  corresponding  to  the  innermost,  and  the  other 
to  the  outermost,  fibers,  inserted  in  the  way  to  be  explained  below  in 
describing  Emmet's  method  for  old  tears. 

Serrefines  are  removed  on  the  fifth  day,  sutures  in  the  incomplete 
laceration  011  the  eighth  day.  In  the  complete  laceration  the  cutane- 
ous are  left  in  nine  or  ten  days ;  the  rectal  take  care  of  themselves, 
catgut  being  dissolved  and  silk  being  allowed  to  cut  through ;  the 
vaginal,  if  silk  has  been  used,  are  removed  after  three  or  four  weeks, 
when  the  perineum  is  strong  enough  to  allow  the  use  of  a  speculum. 
The  same  applies  to  the  deep  laceration  of  the  vaginal  ring. 

Intermediate  Operation. — If  several  days  have  passed  since  the 
laceration  took  place  and  the  surface  has  begun  to  granulate,  it  may 
yet  be  made  to  grow  together.  It  is  for  this  purpose  scraped  with 
the  edge  of  a  knife,  dusted  with  iodoform,  and  united  as  described 
above  with  serrefines  or  sutures.  Union  by  first  intention  has  in  this 
way  been  obtained  in  operations  performed  from  one  to  three  weeks 
after  delivery. 

The  subcutaneous  tear  of  the  levator  ani  muscle  might  be  treated 
in  the  same  way  as  the  open  tear  in  the  same  locality,  after  making 
an  incision  through  the  mucous  membrane  down  to  the  torn  ends  of 
the  muscle.  But,  so  far,  nobody  has  undertaken  this  at  the  time 
of  delivery,  so  far  as  I  know,  and  I  think  such  a  procedure  would 
meet  with  considerable  opposition,  not  only  in  the  public,  but  even 
in  the  profession.  This  accident  is  therefore  left  until  bad  conse- 
quences develop,  and  is  then  operated  on  according  to  the  rules 
presently  to  be  laid  down. 

B.  Old  Lacerations. — If  the  lacerated  perineum  has  not  been 
united  by  the  primary  or  intermediate  perineorrhaphy,  the  so-called 
secondary  perineorrhaphy  will  in  many  cases  become  necessary.  In 
the  mean  time,  the  patient  has  not  only  suffered,  but  some  of  the 
conditions  enumerated  above  may  have  formed,  and  the  shape  of  the 
parts  involved  has  been  changed.  Instead  of  broad  surfaces  corre- 
sponding to  one  another,  we  have  irregularly  contracted  cicatrices. 
In  some  way  or  other  new  raw  surfaces  must,  therefore,  be  produced, 
and,  as  the  cicatrices  are  much  smaller  than  the  original  tear,  it 
becomes  necessary  to  borrow  from  the  surroundings  and  unite  tissues 
that  do  not  belong  to  one  another  in  the  normal  condition. 

Of  the  very  large  number  of  operations  invented  for  the  repair  of 
old  lacerations  of  the  perineum,  we  will  describe  three  only,  one  of 
which,  in  my  opinion,  will  give  satisfaction  in  any  case : 

1.  Tait's  Flap-splitting   Operation.1 — a.  Incomplete  Laceration. — 

1  Tait's  priority  has  been  contested,  and  I  have  myself  seen  Demarquay  operate  by 
the  flap-method  in  Paris  in  1872,  many  years  before  anybody  had  heard  of  Tait's 
operation  of  this  kind,  but  there  can  be  no  doubt  that  the  revival  and  simplification 
of  the  operation  are  due  to  the  great  gynecologist  of  Birmingham. 


308 


DISEASES  OF   WOMEN. 


The  patient  is  placed  on  the  table  in  the  dorsal  position,  with  knees 
drawn  up  by  Clover's  crutch  or  Robb's  leg-holder  (p.  199).  The 
left  index-  and  middle  fingers  are  introduced  into  the  rectum.  One 
blade  of  sharp-pointed  scissors,  bent  on  the  edge,  is  pushed  in  in  the 
median  line,  midway  between  the  anus  and  the  posterior  commissure, 
to  a  depth  of  about  f  inch.  It  is  next  pushed  over  to  the  patient's 
left  side  in  a  curved  line  ending  at  the  anterior  edge  of  the  labium 
majus,  at  a  point  situated  at  such  a  distance  from  the  clitoris  that 
there  is  left  just  room  enough  for  copulation.  All  these  tissues  are  cut 
through  with  one  sweep  of  the  scissors.  These  are  now  brought 
back  to  the  starting-point,  turned  with  the  points  to  the  right,  and  a 
similar  incision  is  made  on  this  side.  The  wound  gapes,  and  is  made 
to  gape  wider  by  pulling  the  cut  surfaces  apart.  If  arteries  spurt, 

FIG.  206. 


Tait's  Perineal  Flap-splitting  Operation  for  Incomplete  Laceration  (MacPhatter). 

they  are  caught  with  pressure-forceps  and  may  be  tied  with  catgut 
(Fig.  206). 

A  handled  needle,  slightly  curved  near  the  end,  is  pushed  through 
the  skin  -fa  inch  outside  of  the  wound,  and  about  |  inch  behind 

One  difficulty  in  describing  his  operation  arises  from  the  fact  that  he  has  per- 
formed it  in  different  ways,  and  that  those  who  have  seen  him  operate  have  given 
very  different  descriptions  of  it — e.  g.  Macphatter  (Amer.  Jour.  Obst.,  Nov.,  1889,  vol. 
xxii.  p.  1146)  and  Munde"  (ibidem,  July,  1889,  p.  673).  In  the  text  I  describe  it  as 
I  have  performed  it  myself  with  good  results. 


DISEASES  OF  THE  PERIS EUM. 


309 


the  anterior  end  of  the  incision,1  passes  under  the  cut  surface, 
emerges  on  the  boundary-line  between  the  cut  surface  and  the  inner 
portion  of  skin  (vaginal  flap),  is  carried  over  to  the  other  labium, 
reinserted  at  the  corresponding  point,  pushed  under  the  right  cut 
surface,  and  out  through  the  skin  y1^  inch  outside  of  the  wound.  A 
piece  of  silkworm  gut  10  inches  long  is  drawn  through  the  eye  of 
the  needle ;  the  latter  is  pulled  back  and  freed  from  the  suture, 
the  two  ends  of  which  are  held  together  with  a  pressure- forceps, 
and  thrown  up  on  the  abdomen.  Another  suture  is  introduced  in  a 
similar  way  J  inch  farther  back.  One  of  the  sutures  ought  to  catch 
the  end  of  the  vaginal  flap.  One,  two,  or  three  more,  according  to 
the  size  of  the  wound,  are  introduced  under  the  whole  cut  surface 
behind  the  vaginal  flap.  In  tightening  the  sutures  care  is  taken  to 
adapt  the  cut  surfaces  against  one  another.  The  outer  flaps  of  each 
\  on  the  two  sides  are  turned  outward,  and  the  inner  turned  inward, 
and  when  the  sutures  are  tightened  they  are  in  this  way  approximated 

FIG.  207. 


Tail's  Perineal  Flap-splitting  Operation  for  Complete  Laceration  (MacPhatter) :  1  to  1,  first 
transverse  incision ;  1  to  2,  incisions  forming  vaginal  flap ;  3  to  4,  incisions  forming  rectal 
nap. 

as  plane  surfaces,  and  so  they  unite.     If  there  is  much  redundant 
tissue  to  dispose  of,  the  vaginal  flap  is  turned  forward  and  a  special 

1  Tait  teaches  to  insert  the  needle  well  within  the  margin  of  the  wound  ( Diteaxe* 
of  Women,  i.  p.  67 ),  but  in  my  hands  the  sutures  cut  through  if  placed  in  that  way, 
and  the  skin  is  not  accurately  brought  together. 


310 


DISEASES  OF  WOMEN. 


suture  passed  through  its  whole  width.  Between  each  two  of  the 
deep  sutures  a  superficial  catgut  suture  is  put  through  the  skin  alone. 
6.  Complete  Laceration  (Fig.  207). — The  cicatrix  in  the  recto- 
vaginal  septum  being  put  on  the  stretch  by  separating  the  buttocks, 
the  scissors  are  run  from  one  end  of  it  to  the  other  (Fig.  208,  A\ 
making  an  incision  about  f  inch  deep,  by  which  are  formed  a  vaginal 
and  a  rectal  flap.  From  each  end  of  this  first  incision  another  is 

FIG.  208. 
A 


Diagrams  illustrating  Incisions  and  Sutures  in  Tait's  Operation  for  Complete  Laceration  of 
the  Perineum  :  A,  first  incision  following  the  cicatricial  line  between  rectum  and  vagina, 
the  buttocks  being  stretched  (natural  size) ;  B,  incisions  to  anterior  edge  of  labium  majus 
and  outside  of  anus  (without  tension) ;  C,  naps  thrown  up  and  down  and  put  on  the  stretch ; 
sutures  inserted  in  the  order  marked :  the  third  corresponds  to  the  angle  between  the  flaps 
(the  bottom  of  the  first  incision);  the  first  goes  right  through  the  ends  of  the  broken  sphinc- 
ter ;  D,  continuous  catgut  suture  carried  through  the  edges  of  the  wound,  now  turned  into 
the  vagina  (the  same  as  the  upper  edge  of  the  first  incision,  B,  a  b). 

carried  at  an  obtuse  angle,  forward  and  outward,  into  each  labium 
majus  for  about  an  inch  (Fig.  208,  B,  a  d  and  6  c),  and,  again  start- 
ing from  the  ends  of  the  first,  a  fourth  and  fifth,  one-third  of  an  inch 
in  length,  are  made  backward  and  outward  (Fig.  208,  J5,  a  f  and 
6  e)  just  outside  of  the  ends  of  the  torn  sphincter. 

The  vaginal  flap  is  held  upward,  the  angles  dab  and  c  b  a  being 
pulled  by  forceps  diagonally  upward  and  inward  toward  the  median 
line.  The  rectal  flap  is  held  downward,  the  angles  fab  and  e  b  a 
being  pulled  in  a  similar  manner  downward  and  inward.  Thus  the 


DISEASES   OF  THE  PERIXEUM.  311 

lines  d  f  and  c  e  become  curved  with  convexity  turned  outward 
(Fio-.  208,  C,  aa  and  66).  The  needle  is  carried  as  described  above, 
with  this  difference,  that  it  is  made  to  emerge  about  ^  inch  from 
the  bottom  of  the  wound  and  enter  at  the  corresponding  point 
on  the  opposite  side  (except  the  hindmost  closing  the  sphincter, 
which  is  buried  altogether).  The  sutures  are  inserted,  beginning 
at  the  anus  and  going  forward.  Finally,  the  middle  of  the  raw 
edge  a  b,  now  situated  in  the  new-formed  vagina,  is  seized  with  a 
tenaculum,  and  the  wound  closed  with  a  continuous  suture  of  fine 
catgut  (Fig.  208,  D). 

If  there  has  been  much  loss  of  tissue  by  previous  denuding  opera- 
tions, deep  relaxing  incisions  should  be  made  parallel  to  the  ramus 
of  the  ischium  on  both  sides.  The  sutures  are  left  in  for  three  or 
four  weeks,  the  bowels  being  kept  loose.  The  ends  of  the  sutures 
should  be  left  rather  long  (J  inch),  as  they  become  deeply  imbedded 
and  are  hard  to  find. 

Tait's  operation  is  by  far  the  most  expeditious  perineorrhaphy,  and 
results  in  the  formation  of  a  thick  and  broad  beam  between  the  anus 
and  the  vulva.  For  the  complete  tear  it  is,  in  my  experience,  superior 
to  all  others.  It  is  easy  to  perform,  takes  a  short  time,  and  yields 
perfect  results. 

2.  a.  Incomplete  Laceration. — Hegar-Garrigues1  Colpoperineor- 
rhaphy.1 — The  patient  is  in  the  dorsal  posture,  as  in  the  preceding 
operation.  The  object  is  to  remove  the  whole  vaginal  wall  and  the 
mucous  membrane  of  the  vulva  over  a  triangular  surface  on  the  pos- 
terior part  of  the  vagina  and  vulva,  bring  the  two  halves  together 
from  side  to  side,  and  at  the  same  time  lift  the  posterior  wall  of  the 
vagina  up  against  the  anterior. 

According  to  the  amount  of  tear  and  relaxation  of  the  vaginal 
entrance  and  the  perineum,  a  point  (Fig.  209,  A,  a]  is  chosen  in  the 
median  line  more  or  less  high  up  toward  the  cervical  portion.  This  is 
pulled  forward  and  upward  with  a  pair  of  bullet-forceps  with  catch  or  a 
tenaculum-forceps.  A  small  nick  is  made  on  the  inside  of  each  labium 
majus  near  the  edge  at  such  a  distance  from  the  clitoris  that  there  will 
be  left  proper  space  for  copulation  (6  and  c).  The  triangle  formed 
between  these  three  points  is  put  on  the  stretch,  and  another  pair 
of  bullet-forceps  introduced  where  the  side  line  of  the  triangle 
intersects  the  furrow  on  either  side  of  the  vagina  (d  and  e\  With  a 
blunt-pointed  pair  of  scissors,  bent  on  the  flat,  and  with  the  concave 
side  turned  toward  the  operator,  a  small  incision  is  made  through 
the  vaginal  wall  just  inside  of  the  forceps  on  the  patient's  left 
side,  and  the  scissors  pushed  up  under  the  wall  to  the  forceps 
at  the  upper  end  of  the  triangle,  and  then  swept  down  to  the  third 

1  I  describe  this  operation  with  such  modifications  as  have  proved  of  practical 
value  in  my  own  hands. 


312  DISEASES  OF  WOMEN. 

forceps  on  the  right  side,  all  of  which  is  doue  with  the  greatest  facil- 
ity and  without  great  loss  of  blood.  Next,  this  upper  part  of  the  tri- 
angle is  cut  loose  on  the  two  lateral  sides  (e  a  and  a  d).  The  scissors 
are  then  introduced  at  c,  the  nick  made  on  the  left  labium,  and  pushed 
up  to  e  and  down  to  the  line  of  demarkation  between  the  mucous 
membrane  and  the  skin  and  over  toward  the  other  side.  Finally, 
they  are  introduced  at  6,  the  nick  made  on  the  right  labium,  and  used 
in  a  similar  way  until  the  lower  part  of  the  triangle  is  denuded.  The 
more  we  approach  the  base  (6  c)  the  more  the  mucous  membrane 
adheres,  and  it  may  be  bound  to  the  underlying  parts  by  cicatricial 
tissue,  which  may  require  small  uicks  with  the  scissors.  Finally, 
the  flap  is  cut  off  along  the  lines  e  c,  c  b,  and  6  d. 

Sutures  are  put  in  from  above  downward  at  a  distance  of  a  quarter 
of  an  inch  from  one  another,  deep  ones  alternating  with  superficial 
ones,  which  latter  go  through  the  edges  of  the  mucous  membrane 
only.  Near  the  upper  end  the  deep  are  buried  all  the  way  under 
the  raw  surface.  When  the  surface  becomes  broader,  the  needle  is 
brought  out  a  quarter  of  an  inch  from  the  median  line  and  reinserted 
at  the  corresponding  point  on  the  other  side.  The  following  sutures 
(Fig.  198,  A,  5,  7,  9)  are  not  carried  horizontally  across,  but  made  to 
dip  toward  the  base  of  the  triangle,  so  that  when  tightened  they  will 
raise  the  posterior  wall  forward  and  upward.  Thus  one  suture  is 
inserted  and  tied  after  the  other  until  the  lines  /  c  and  /  b  (Fig.  198, 
B)  have  the  same  length  as  g  c  and  g  b.  Then  a  silkworm  suture 
(10)  is  carried  deep  under  the  wound  from  a  point  about  half  an  inch 
from  the  median  line  (g)  and  f  inch  from  the  edge  of  the  denuded  sur- 
face up  under  the  wound,  about  two-thirds  of  the  distance  from  the  end 
of  the  closed  line  (/),  and  down  to  the  corresponding  point  on  the  other 
side.  A  second  suture  (1 1 )  is  inserted  midway  between  the  ti rst  and  the 
point  c,  brought  out  on  the  edge  of  the  denuded  surface  at  //,  reinserted 
on  the  other  side  at  i,  and  brought  out  on  the  skin.  Finally,  the  last 
suture  (12)  is  inserted  near  the  outer  end  of  the  wound  (c),  brought 
out  at  k  midway  between  h  and  c,  reinserted  at  i,  the  corresponding 
point  on  the  other  side,  and  brought  out  on  the  skin  below  6.  These 
three  sutures  are  not  tightened  until  all  are  put  in  and  the  surface 
well  irrigated.  The  direction  given  to  the  sutures  ensures,  a  very 
perfect  adaptation  of  the  edges,  and  makes  the  surfaces  that  come  in 
contact  sufficiently  broad  to  form  an  excellent  substitute  for  the 
original  perineal  body. 

1  use  catgut,  medium-sized  for  the  deep,  and  fine  for  the  superficial 
vaginal  sutures,  and  silkworm  gut  for  the  perineum.  Each  vaginal 
suture  is  tied  and  cut  as  soon  as  it  is  inserted.  Large  curved  Hage- 
dorn's  needles  can  be  used  in  most  cases.  Finally,  in  order  to  ensure 
perfect  adaptation  of  the  edges,  a  couple  of  superficial  silk  sutures  are 
introduced  on  the  perineum,  between  the  deep  sutures  (Fig.  209  C). 


DISEASES  OF  THE  PERINEUM. 

FIG.  209. 

—  "•->. 

o 
/^ 

A 


313 


A,  Hegar-Garrigues'  Colpoperineorrhaphy :  sutures  5,  7,  and  9  slant  downward  toward  tin- 
entrance,  and  are  brought  out  about  a  quarter  of  an  inch  from  the  median  line;  B,  the 
triangle  shown  in  A  having  been  closed,  the  perineal  sutures  are  inserted— 10,  all  buried : 
11  and  12,  partly  free— all  in  a  slanting  direction ;  C,  perineal  sutures  tied. 


314  DISEASES  OF   WOMEN. 

I  remove  the  middle  perineal  suture  on  the  fifth  day,  the  others  on 
the  eighth. 

Buried  Catgut  Sutures. — Some  prefer  to  close  the  whole  wound 
with  buried  catgut  sutures,  either  interrupted  or  continuous.  The 
latter  is  begun  at  the  upper  end  of  the  triangle,  and  the  first  circle 
closed  with  a  knot,  leaving  the  end  three  inches  long.  This  end  is 
seized  with  a  pair  of  forceps  and  pulled  upward  by  an  assistant, 
which  facilitates  the  introduction  of  the  remaining  sutures  very  much. 
The  needle  is  introduced  through  the  edges  of  the  mucous  membrane 
and  under  the  raw  surface  until  the  tension  becomes  too  great,  when 
the  suture  is  continued  in  the  depth  of  the  wound  down  to  the 
vaginal  entrance.  From  this  it  is  carried  upward,  forming  a  second 
row  of  buried  spirals,  after  which  it  is  brought  down  between  the 
edges  of  the  mucous  membrane,  and  finally  down  the  perineum.  It 
is  tied  as  stated  in  describing  tier-sutures  (p.  221). 

b.  Complete  Laceration. — Hegar's  Operation.1 — The  patient  is  in 
the  dorsal  position.  The  buttocks  are  pulled  aside  and  the  anterior 
vaginal  wall  lifted  up  with  Siras's  speculum.  A  sponge  soaked  in  an- 
tiseptic fluid,  or  a  pad  of  iodoform  gauze,  may  be  introduced  into  the 
rectum,  and  withdrawn  before  the  last  rectal  sutures  are  introduced. 

A  tenaculum-forceps  is  introduced  at  x  (Fig.  210)  in  the  median 

FIG.  210. 


c  d 

Hegar's  Operation  for  Complete  Laceration  of  the  Perineum. 

line  of  the  posterior  vaginal  wall,  three-quarters  of  an  inch  above  e, 
which  is  the  upper  point  of  the  tear  in  the  recto-vaginal  partition. 
Two  other  pairs  of  tenaculum-forceps  are  introduced  at  a  and  6  on 
the  lower  edge  of  the  labia  majora,  at  the  distance  from  the  clitoris 
where  we  want  the  posterior  commissure  to  be,  slightly  above  the 
anterior  end  of  the  cicatrice  marking  the  situation  of  the  old  perineal 
body.  These  three  points  are  now  put  on  the  stretch,  and,  beginning 

1  For  simplicity's  sake  I  leave  this  operation  under  Hegar's  name,  but  it  has 
evolved  gradually  in  the  hands  of  Dieffenbach,  Simon,  and  others. 


DISEASES  OF  THE  PERINEUM.  315 

at  x,  the  operator  draws,  with  the  point  of  a  scalpel,  a  curved  line  to 
6,  with  the  convexity  turned  toward  himself.  Next  he  continues  the 
line  from  6  to  <7,  with  a  slightly  convex  curve  outward,  down  to  a 
point  just  outside  and  behind  the  pit  marking  the  torn  sphincter. 
Next,  an  exact  counterpart  of  this  line  is  drawn  on  the  right  side. 
Finally,  the  pit  is  seized  with  a  tenaculum  and  cut  off  with  blunt 
scissors  curved  on  the  flat,  and  the  strip  continued  along  the  whole 
edge  of  the  rent  in  the  rectum  over  to  the  corresponding  point  on 
the  other  side,  so  as  to  remove  all  the  cicatricial  tissue.  The  mucous 
membrane  is  seized  in  the  middle  of  the  incision,  at  e,  with  a  toothed 
forceps,  and  the  scissors  pushed  up  under  it  to  the  limits  of  the  sur- 
face circumscribed  with  the  scalpel.  Where  it  meets  with  resistance 
small  nicks  are  made  through  the  resisting  tissue.  Finally,  the  flap 
thus  formed  is  cut  off  with  the  scissors. 

It  is  rarely  necessary  to  use  hemostatic  forceps  on  bleeding  vessels. 
If  so,  the  tissue  grasped  between  the  jaws  of  the  forceps  should  be 
cut  away  before  closing  the  wound,  in  order  to  avoid  having  any 
dead  tissue  in  its  depth.  Fine  silk  (braided  No.  2)  is  best  for  the 
rectal  sutures,  silkworm  gut  for  the  vaginal  and  perineal.  Only 
round  needles,  straight  and  curved,  two  inches  long,  should  be  used. 
Cutting  needles  make  large  holes  in  the  soft  tissues  to  be  united, 
which  seriously  interfere  with  success. 

The  first  suture  is  put  in  a  little  below  x,  and  followed  by  several 
others  parallel  to  it  running  from  side  to  side  under  the  whole  raw 
surface,  x  m  n.  In  order  to  avoid  penetrating  into  the  rectum  the 
movements  of  the  needle  are  guided  with  the  finger  in  the  intestine. 

Next,  some  rectal  sutures  are  inserted.  The  needle  is  introduced 
on  the  rectal  surface  -fg  inch  below  the  top  of  the  rent,  and  at  the 
same  distance  from  the  edge,  and  carried  under  the  raw  surface  above 
the  rent,  pushed  out  in  the  median  line,  reintroduced  with  the  point 
turned  down  in  the  same  place,  carried  under  the  raw  surface  on  the 
right  side,  and  out  on  the  rectal  surface  at  a  point  corresponding  to 
that  of  entrance.  The  following  rectal  sutures  are  merely  pushed  in 
a  slanting  line  from  the  rectum  to  the  raw  surface  outside  it  on  the 
left  side,  introduced  in  the  corresponding  place  on  the  right  side,  and 
carried  down  through  the  rectal  wall.  Thus  raw  surfaces  are  brought 
in  contact  and  the  edges  turned  into  the  rectum.  The  last  two  sutures 
are  made  to  embrace  the  ends  of  the  broken  sphincter.  The  rectal 
sutures  are  quite  close  to  one  another,  about  -^  inch  apart,  superficial 
alternating  with  deep.  Next,  the  lines  m  a  and  n  b  are  brought 
together  with  sutures  ^  inch  apart,  alternately  a  deep,  reaching  half- 
way under  the  raw  surface,  and  a  superficial.  Finally,  four  or  five 
are  placed  rather  superficially  on  the  perineum.  Every  suture  is  tied 
and  cut  immediately  when  inserted,  the  ends  being  turned  up  out  of 
the  way  of  the  following  suture. 


316 


DISEASES  OF  WOMEN. 


If  the  tear  is  over  1 J  inches  long,  the  upper  half  of  it  is  stitched 
from  the  vagina  alone,  the  septum  being  too  thin  for  a  vaginal  and 
a  rectal  row  of  sutures.  The  lower  half  is  treated  as  described  above. 

Silk  threads  entering  the  rectum  become  easily  conductors  of  septic 
material,  and  small  abscesses  form,  which  often  result  in  a  small  recto- 
vaginal  fistula.  This  may  be  obviated  by  using  buried  submucous 
catgut  sutures  (Fig.  21.1).  These  sutures  are  introduced  from  the 
raw  surface  a  quarter  of  an  inch  from  the  edge  to  be  united,  and 
pushed  out  on  the  same  surface  quite  near  the  edge,  inserted  on  the 
corresponding  point  near  the  opposite  edge,  and  pushed  out  a  quarter 
of  an  inch  from  the  edge  on  the  raw  surface.  The  vaginal  sutures 


Submucous  Sutures  (Lauenstein) :  r,  rectum ;  v,  vagina. 

are  put  in  in  the  same  way,  and  finally  the  perineum  is  closed  with 
silver-wire  or  silkworm-gut  sutures.1 

For  incomplete  laceration  in  cases  where  the  inner  ring  has  suffered 
much,  my  modification  of  Hegar's  operation  is  in  my  opinion  the  best. 
It  interposes  between  the  vulvo-vaginal  canal  and  the  rectum  a  strong 
wedge  reaching  up  as  far  as  the  operator  wishes,  and  this  body  is  sus- 
pended from  above,  being  attached  to  the  bones  of  the  pelvis. 

In  cases  of  complete  laceration,  on  the  other  hand,  one  is  very  apt 
to  get  a  small  recto-vaginal  fistula  by  Hegar's  method. 

3.  T.  A.  Emmet's  Operation. — a.  Incomplete  Laceration.2 — The 
aim  of  this  operation  is  to  lift  up  the  pelvic  floor  and  dispose  of  a 
so-called  rectocele. 

The  patient  is  in  the  dorsal  position,  with  bent  knees  and  with 
feet  held  up  by  two  assistants. 

First  Step. — The  top  of  the  rectocele  (Fig.  212,  A,  a)  is  caught  with 
a  tenaculum  and  held  by  an  assistant  over  to  the  left  side  of  the  vulva. 

1  Carl  Lauenstein,  CentralblaU  f.  Gynak.,  1886,  vol.  x.  p.  50. 

*  This  is  Dr.  Emmet's  new  operation.  His  old  was  like  that  for  complete  lacera- 
tion with  the  exception  of  what  has  reference  to  the  tear  in  the  septum. 


DISEASES  OF  THE  PERINEUM.  317 

Another  tenaculum  is  inserted  at  the  caruncula  myrtiforrnis  on  the 

FIG.  212. 


Diagram  of  T.  A.  Emmet's  Operation  for  Incomplete  Laceration  of  the  Perineum. 


FIG.  213. 


\ 


right  side  (6).  A  third  tenaculum  is  inserted  at  the  posterior  com- 
missure (c).  Finally,  a  fourth  tenaculum 
is  inserted  at  d  ;  that  is,  a  point  so  far  up 
*in  the  side  sulcus  of  the  vagina  that  it 
does  not  yield  on  being  pulled  down.  The 
four  tenacula  being  pulled  in  divergent 
directions,  a  rhomboidal  part  of  the  mu- 
cous membrane  of  the  vagina  is  put  mod- 
erately on  the  stretch,  and  the  isosceles 
triangle,  a  d  6,  denuded  with  two  snips  of 
curved,  rather  sharp-pointed  scissors  from 
below  upward.  Next,  silver  sutures  are 
put  in,  forming  curves,  or  rather  angles, 
the  top  of  which  points  down  toward  the 
vulva,  the  operator  guiding  himself  by  in- 
troducing a  finger  into  the  patient's  rectum 
(Fig.  213).  While  they  are  being  passed 

the  assistant  always  lifts  the  last,  in  order  to  check  hemorrhage. 
Second  Step  (Fig.  212,  B). — The  top  of  the  rectocele  is  carried 


Emmet's  Suture  for  lifting  the 
Pelvic  Floor:  The  needle  is  in- 
troduced at  a,  pushed  out  at  b. 
and  when  it  has  been  pulled 
through,  it  is  reinserted  at  b 
and  carried  to  c. 


318 


DISEASES  OF  WOMEN. 


over  to  the  right  side,  and  the  triangle,  a  f  e,  on  the  left  side  treated 
in  the  same  way  as  the  right. 

Third  Step  (Fig.  212,  C). — The  patient's  feet  being  lowered  to  the 
top  of  the  table,  the  surface,  a  b  e  g — that  is,  all  the  mucous  mem- 
brane between  the  top  of  the  rectocele,  the  two  carunculse  myrtiformes 
on  the  side  of  the  vaginal  entrance,  and  a  curved  line  running  a  quar- 
ter of  an  inch  inside  of  the  posterior  circumference  of  the  rima  pudeudi 
and  parallel  with  it — is  denuded,  and  sutures  are  put  in  from  side  to 
side.  One  is  carried  through  the  two  caruuculae,  6  and  e,  and  behind 
the  tip  of  the  tongue  of  mucous  membrane  left  between  the  denuded 
surfaces,  a.  Three  or  four  more  are  put  in  from  side  to  side,  as  seen 
in  the  figure,  all  entering  on  the  mucous  membrane  inside  of  the  skin. 

Fourth  Step. — The  sutures  are  twisted,  beginning  from  the  tops  of 
the  triangles,  d  and  /,  and  ending  at  g,  cut  oif,  and  bent  backward 
into  the  vagina.  When  all  are  closed  they  form  a  Y,  and  are  all  in 
the  vagina  and  the  vulva,  while  the  skin  is  not  touched  at  all. 

This  operation  reduces  the  parts  to  a  condition  very  much  like  in 
appearance  the  normal  one,  but  it  requires  more  time,  more  skill,  and 
better  assistance  than  the  other  operations. 

Outerbridge 1  has  simplified  Emmet's  operation  by  using  only  three 
sutures.  The  first  is  medium-sized  catgut,  10  to  12  inches  long,  armed 

FIG.  214. 


Outerbridge's  Suture.    The  sutures  are  numbered  in  the  order  in  which  they  are  tied,  not 

inserted. 

with  a  straight  cervix-needle  at  each  end.     It  is  passed  from  the  end 

of  the  central  undenuded  tongue  to  the  upper  end  of  the  lateral  denu- 

1  Outerbridge,  Med.  Record,  April  21,  1894,  vol.  xlv.  p.  493. 


DISEASES  OF  THE  PERINEUM. 


319 


dation  on  both  sides.  It  is  not  tied,  but  the  needles  are  thrown  up 
over  the  symphysis.  Next,  the  second  suture,  which  is  of  silver  wire, 
is  passed  from  the  highest  point  of  the  denudation  on  the  labium 
majus,  under  the  whole  wound,  across  to  the  corresponding  point  on 
the  other  side.  Then  the  first  suture  is  tied,  and  from  this  now  cen- 
tral point  one  of  the  needles  is  passed  under  the  denuded  surface  and 
brought  out  on  the  inside  of  the  labium,  half  an  inch  above  the 
lowest  point  of  denudation.  The  other  needle  is  passed  in  the  same 
way  to  the  corresponding  point  on  the  other  labium.  Now  this  lower 
suture  is  drawn  tight  and  tied.  Finally,  the  silver  suture  is  twisted. 
The  bowels  are  moved  on  the  third  day,  and  the  silver  suture  removed 
on  the  eighth  (Fig.  214). 

Cleveland's  Suture. — Cleveland T  has  recommended  the  use  of  cat- 
gut and  passing  the  suture  in  the  shape  of  the  figure  8.     The  first 

FIG.  215. 


Cleveland's  Suture. 


suture  (A,  Fig.  215)  is  passed  in  at  1,  midway  between  the  posterior 

commissure  (D)  and  the  upper  end  of  the  denudation  on  the  left 

labium,  a  quarter  of  an  inch  outside  of  the  edge,  is  carried  well  back 

1  Clement  Cleveland,  Medical  Record,  Feb.  14,  1891,  vol.  xxxix.  p.  193. 


320  DISEASES  OF  WOMEN. 

deep  under  the  tissues  so  as  to  embrace  the  retracted  muscles,  across 
between  the  denuded  surface  and  the  rectum,  to  the  center  of  the 
denuded  surface,  then  down  and  out  a  quarter  of  an  inch  from  the 
edge,  at  2,  situated  on  the  right  labium,  midway  between  the  point 
corresponding  to  1  and  the  posterior  commissure  (Z)).  It  is  then 
entered  at  3,  the  point  on  the  left  labium  corresponding  to  2,  brought 
under  the  denuded  surface  to  its  center,  and  then  out  at  4,  which 
corresponds  to  1. 

The  second  suture  (B)  is  passed  in  a  similar  way.  It  is  entered  at 
l,a  point  just  below  the  summit  of  the  denudation  on  the  left  labium, 
and  passed,  buried  close  to  the  denuded  edge,  around  the  angle  in  the 
left  sulcus  to  the  highest  point  of  denuded  surface  on  the  columna 
(C),  and  thence,  still  buried,  across  to  2,  situated  midway  between 
the  upper  end  of  the  denudation  on  the  right  labium  and  4,  where 
the  first  suture  came  out.  Here  it  is  brought  out,  a  quarter  of  an 
inch  from  the  edge,  re-entered  at  3,  the  corresponding  point  on  the 
left  labium,  carried  to  C,  then  close  to  the  edge  of  the  denuded  sur- 
face at  the  right  lateral  sulcus,  and  out  at  4,  which  corresponds  to  the 
first  point  of  entrance,  B  1.  As  a  protection  a  third  suture  (E)  is 
usually  introduced  just  above  the  upper  end  of  the  denuded  surface 
on  the  left  labium,  carried  through  the  labium,  and  out  on  the 
mucous  membrane  ;  then  it  takes  up  about  a  third  of  an  inch  of 
mucous  membrane  on  the  columna  at  C,  and  finally  passes  through 
the  right  labium.  This  protection  suture  should  be  of  silver  wire 
or  silkworm  gut.  It  becomes  unnecessary  if  one  of  these  materials 
has  been  used  for  the  two  other  sutures. 

The  sutures  are  closed  from  behind  forward  in  the  order  they  have 
been  put  in. 

In  extreme  cases  of  extension  of  the  laceration  into  one  or  both 
sulci,  the  Emmet  sutures  may  be  used  to  close  the  angles,  or  the 
Cleveland  suture  may  be  applied  separately  to  each  angle  before  the 
two  perineal  sutures  are  inserted. 

6.  Complete  Laceration.  —  Special  care  is  taken  to  get  the  entire 


FIG.  216. 


Diagram  of  Broken  Sphincter  Ani  Muscles  (T.  A.  Emmet):  D  C,  first  suture;  B  A,  second 

suture. 

ends  of  the  broken  sphincter  brought  together.     The  above-men- 


DISEASES  OF  THE  PERINEUM. 


321 


FIG.  217. 


tioned  pits  marking  these  ends  are  seized  with  a  tenaculum  and 
removed,  together  with  a  strip  of  mucous  membrane  on  the  posterior 
vaginal  wall  and  the  internal  surface  of  the  labia  majora,  as  in 
Hegar's  operation.  The  first  suture  (Dr.  Emmet  uses  always  silver 
wire)  is  inserted  a  quarter  of  an  inch  behind  and  inside  the  end  of 
the  broken  and  retracted  sphincter  muscle,  which  now  forms  a  convex 
surface  (Fig.  216),  and  carried  under  the  denuded  surface  parallel  to 
the  rent  in  the  recto-vaginal  septum,  so  as  to  unite  the  innermost 
fibers  of  the  sphincter  (Fig.  217,  C,  D\  The  second  suture  (A,  B) 
is  inserted  at  the  outer  end  of  the  broken 
sphincter  and  carried  around  the  rent  in 
the  septum,  parallel  to  the  first.  These 
two  sutures  when  closed  bring  the  two 
ends  of  the  broken  ring  together,  and 
unite  it  at  the  same  time  with  the  lower 
end  of  the  septum.  Next,  a  couple  of 
sutures  (Fig.  218,  3  and  4)  are  brought 
from  the  perineum  under  the  whole  de- 
nuded surface  over  to  the  other  side,  the 
uppermost  comprising  the  end  of  the  un- 
denuded  part  of  the  vagina.  The  last  but 
one  (5)  goes  through  the  labium  majus, 
emerges  near  the  side  sulcus  of  the  vagina  just  on  the  line  of 
demarkation  between  the  pared  and  unpared  surface,  enters  the 

FIG.  218. 


Dia 


agram  of  Broken  Sphincter  Ani 
(T.  A.  Emmet),  showing  how  the 
ends  are  brought  together  by 
tightening  the  sutures. 


:  R,  rectum  ;  J ,  vagina ; 


vx 

Diagram  for  Emmet's  Operation  for  Complete  Laceration  of  Perineum :  R,  rectum  ;  \ 
P,  perineum.    The  figures  mark  the  order  in  which  the  sutures  are  inserted 

corresponding  point  on  the  other  side,  and  emerges  on  the  skin 
opposite  the  point  of  entrance.  The  last  (6)  unites  the  tops  of  the 
denuded  surfaces  on  the  labia  majora. 


322  DISEASES  OF  WOMEN. 

If  the  rent  in  the  recto-vaginal  septum  is  over  one  inch  long,  it 
should  be  diminished  by  denuding  the  vaginal  surface  near  the  edges, 
down  to  the  sphincter,  and  introducing  sutures  from  side  to  side. 
When  these  have  been  removed  after  about  nine  days,  and  the 
denuded  surfaces  have  grown  together,  the  above-described  operation 
for  the  closure  of  the  sphincter  and  perineum  is  performed. 

Outerbridge  uses  his  above-described  three  sutures  after  having 
overstretched  the  sphincter  and  united  the  edges  of  the  gut  either 
with  continuous  or  interrupted  catgut  sutures,  taking  care  to  insert 
one  suture  through  the  ends  of  the  broken  sphincter. 

Preparation  and  After-treatment. — In  regard  to  preparations  for 
any  of  these  operations  for  lacerated  perineum,  the  reader  is  referred 
to  what  has  been  said  in  the  chapter  on  Treatment  in  General  (p.  196). 
The  bowels  are  emptied  and  the  labia  are  shaved,  but  the  hairs  on 
the  mons  Veneris  need  not  be  interfered  with.  The  knees  are  kept 
tied  together  for  two  weeks.  The  diet  during  the  first  few  days, 
until  the  bowels  have  been  moved,  should  be  exclusively  albuminoid 
(milk,  beef  extracts,  raw  oysters,  and  eggs),  so  as  to  have  as  little 
fecal  matter  as  possible. 

As  a  rule,  some  pain  will  call  for  small  doses  of  morphine  (gr.  ^) ; 
otherwise  opiates  should  be  avoided,  as  they  render  the  feces  hard. 
The  patient  may  lie  on  her  back  or  her  side,  but  should  move  slowly 
and  with  the  assistance  of  her  nurse. 

On  the  morning  of  the  fourth  day  Ol.  ric.  fl.^iij  is  given.  When 
the  patient  feels  that  evacuation  is  near,  four  ounces  of  olive  oil 
should  be  injected  into  the  rectum.  In  this  way  an  easy,  loose  move- 
ment or  two  are  brought  on.  Thereafter  every  morning  just  enough 
castor  oil  (about  3ij)  is  given  to  have  one  easy  movement.  The  urine 
should  be  drawn  with  a  catheter.  When,  after  a  few  days,  there 
appears  some  discharge,  a  vaginal  injection  of  carbolized  water  (sss 
to  Oij)  should  be  given  morning  and  evening,  and,  in  complete  lace- 
ration, half  a  pint  of  lukewarm  water  injected  at  the  same  time  into 
the  rectum.  If  the  patient  is  troubled  with  flatus,  much  relief  is 
afforded  by  the  occasional  cautious  introduction  of  a  well-greased 
soft-rubber  rectal  tube  of  the  size  of  the  little  finger. 

As  a  rule,  perineal  sutures  must  be  removed  at  the  end  of  a  week 
(compare  Tait's  method) ;  vaginal,  which  are  difficult  to  reach  with- 
out risking  the  destruction  of  the  union  in  the  perineum,  are  left  in 
for  three  to  four  weeks,  or  more  if  necessary ;  rectal  are  left  to  them- 
selves. In  removing  vaginal  sutures  a  virginal  Sims  speculum  and 
Hunter's  depressor  (p.  147)  will  be  found  very  useful.  The  ends  of 
each  suture  are  seized  separately  with  the  suture-twister  and  lifted  a 
little.  Great  care  should  be  taken  to  insert  one  of  the  points  of  a 
pair  of  pointed  scissors  into  the  loop,  and  cut  close  up  to  the  entrance 
of  the  stitch-canal.  The  sutures  should  be  removed  from  below 


DISEASES  OF  THE  PERINEUM.  323 

upward,  and  when  the  rent  begins  to  bleed  the  removal  of  the  others 
should  be  postponed. 

The  patient  may  leave  the  bed  after  two  or  three  weeks.     Coition 
should  not  take  place  for  two  months. 


CHAPTER  II. 
GARRULITY  OF  THE  VULVA. 

UNDER  the  queer  name  "garrulity  of  the  vulva"  has  been  de- 
scribed a  condition  which  is  characterized  by  the  entrance  of  air  into 
the  vagina  and  its  expulsion  with  a  noise  from  the  same.  Another 
name  for  the  same  phenomenon  is  flatus  vaginalis. 

Etiology. — It  is  a  rare  disease.  It  is  only  possible  when  the  vulva 
and  vaginal  entrance  gape.  It  may  be  due  to  tears  of  the  perineum 
and  vaginal  entrance,  episiotomy,  loss  of  flesh,  and  varicose  veins  of 
the  vulva. 

Treatment. — The  indication  is  to  diminish  the  entrance  to  the  geni- 
tal canal  by  the  performance  of  one  of  the  operations  described  above 
for  laceration  of  the  perineum,  or  by  excision  of  cicatrices  and  union 
by  suture. 

CHAPTER    III. 

COCCYGODYNIA. 

UNDER  the  name  of  "  coccygodynia  "  are  united  different  and  par- 
tially unknown  pathological  conditions,  the  common  feature  of  which 
is  intense  pain  at  the  coccyx,  whence  it  may  radiate  into  the  peri- 
neum, the  hips,  the  uterus,  and  the  bladder. 

Pathological  Anatomy. — Sometimes  there  are  palpable  diseases  or 
deformities  of  the  coccyx,  such  as  caries,  fracture,  aukylosis,  too  great 
•a  length,  luxation,  or  other  displacement.  In  other  cases  the  condi- 
tion is  combined  with  diseases  of  the  uterus,  ovaries,  or  rectum.  In 
a  third  class  it  is  of  a  purely  neuralgic  nature.  It  is  not  unlikely 
that  the  coccygeal  "  gland  "  (p.  103),  with  its  exceedingly  rich  nerve- 
supply,  has  something  to  do  with  it.  Still,  this  gland  is  found  in 
both  sexes  and  at  all  ages,  while  the  disease  is  never  found  in  man, 
and  is  exceedingly  rare  in  childhood. 

Etiology. — The  disease  is  only  found  in  women,  especially  adults 
who  have  borne  children,  but  occurs  also  in  virgins,  and  very  rarely  in 
children.  By  far  the  most  common  cause  is  childbirth.  As  a  rule, 
it  appears  after  tedious  labor  with  long-sustained  pressure,  tears,  or 


324  DISEASES  OF  WOMEN. 

straining  of  muscles  or  ligaments,  or  after  instrumental  delivery ; 
but  it  may  also  begin  before  delivery,  and  is  then  probably  due  to 
the  pressure  of  the  head  against  the  last  two  sacral  and  the  coccygeal 
nerves.  The  disease  is  sometimes  due  to  violence  from  without,  such 
as  a  kick,  a  fall,  or  horseback  riding,  or  to  exposure  to  cold,  especially 
in  individuals  suffering  from  rheumatism.  Sometimes  it  seems  to  be 
a  reflex  neurosis  due  to  muscular  contraction  of  the  sphincter  ani,  the 
levator  ani,  or  the  bulbo-cavernosus  muscles,  such  as  is  found  in  con- 
sequence of  painful  caruncle  or  hemorrhoids. 

Sympto'tns. — Severe  pain  is  felt  in  sitting,  especially  in  sitting  down 
or  getting  up ;  nay,  the  tenderness  may  be  so  great  that  the  patient 
can  only  sit  on  one-half  of  the  nates,  near  the  edge  of  a  chair,  using 
her  hands  to  get  up  and  down.  All  movements  of  the  coccyx  and 
the  ligaments  and  muscles  attached  to  it,  induced  by  walking,  riding, 
defecation,  coition,  etc.,  increase  the  pain  enormously. 

Diagnosis. — The  condition  is  easily  recognized  by  placing  the  pa- 
tient on  her  left  side  and  introducing  the  index-finger  into  the  rectum, 
while  the  thumb  rests  on  the  skin  over  the  coccyx.  The  slightest 
movement  of  the  bone  causes  severe  pain,  and  sometimes  it  may  be 
possible  to  feel  a  diseased  condition  of  the  bone  or  the  surrounding 
parts. 

Treatment. — The  general  treatment  consists  in  tonics  or  antirheu- 
matics.  Suppositories  with  five  grains  of  iodoform  or  one-third  of 
a  grain  of  morphine ;  hypodermic  injection  of  cocaine  or  morphine ; 
inunction  with  ointments  of  veratrine  or  aconitine ;  blisters ;  cauteri- 
zation; and  galvanism  or  faradization  with  the  secondary  current 
with  high  tension  (p.  230) ;  besides  treatment  of  concomitant  diseases 
in  neighboring  organs, — have  each  effected  cures.  But  cases  that 
have  resisted  all  other  remedies  have  yet  been  cured  by  the  extir- 
pation of  the  coccyx,  whether  diseased  or  healthy.  This  operation,, 
which  may  be  called  coccygectomy,  is  performed  by  placing  the  patient 
on  the  right  side  or  on  the  abdomen,  introducing  the  index  finger  of 
the  left  hand  into  her  rectum,  pressing  it  outward,  and  making  an  in- 
cision in  the  median  line,  about  four  inches  long,  and  reaching  from 
half  an  inch  below  the  tip  to  one  and  a  half  inches  above  the  base, 
down  to  the  bone.  The  soft  tissues  are  pushed  aside  with  a  blunt  in- 
strument and  a  few  touches  of  the  knife,  until  the  whole  bone,  inclusive 
of  the  projecting  transverse  processes  of  the  uppermost  vertebra,  is  laid 
bare.  The  attachments  of  the  bone  throughout  its  whole  length  are 
freely  separated  on  each  side,  and  the  knife  passed  through  the  articu- 
lation with  the  sacrum  and  the  lateral  ligaments.  The  left  hand  is 
now  disengaged,  and,  armed  with  Fergusson's  bulldog-forceps,  used  to 
seize  the  bone,  which  is  pulled  firmly  outward,  while  some  flat,  blunt 
instrument  like  Hay's  director  is  passed  behind  it  and  severs  all  re- 
maining connections,  except  the  tendon  of  the  levator  ani  muscle. 


DISEASES  OF  THE  PERINEUM.  325 

which  has  to  be  cut  with  a  knife.  In  exceptional  cases  it  may  be- 
come necessary  to  sever  the  bone  with  a  cutting  bone-forceps  or  a  small 
saw.  As  a  rule,  there  is  not  much  hemorrhage,  and  the  wound  may 
be  united  by  deep  interrupted  sutures  (preferably  silkworm  gut).  If 
there  is  much  hemorrhage,  it  may  be  necessary  to  pack  the  wound 
with  styptic  cotton  and  let  it  heal  by  granulation. 

The  coccyx  in  women  is  flat  and  shorter  than  in  man,  about  two 
inches  long,  and  forms  a  nearly  equilateral  triangle.  When  it  is  re- 
moved, we  look  into  a  deep  hollow,  at  the  bottom  of  which  is  seen 
the  levator  ani  muscle,  covered  by  the  anal  fascia  (p.  95).  The  deep 
sutures  ought  to  embrace  all  the  edge,  inclusive  of  the  severed  lesser 
sacro-sciatic  ligament,  but  not  the  levator  ani  muscle. 

After  the  operation  the  patient  is  pulled  down  over  the  end  of  the 
table ;  the  wound  is  dusted  with  iodoform,  covered  with  iodoform 
gauze  and  cotton,  and  a  double  spica  is  applied,  inserting  a  piece  of 
gutta-percha  tissue  so  as  to  leave  the  anus  and  vulva  free  and  keep 
the  dressing  clean.  The  sutures  are  removed  after  a  week. 


CHAPTER    IV. 

HYGROMA. 

UNDER  the  redundant  name  of  "  perineal  cystic  hygroma "  has 
been  described  a  cystic  tumor  formed  by  an  accumulation  of  fluid  in 
the  cavities  of  the  coccygeal  gland.  It  forms  a  round,  elastic,  immov- 
able tumor,  situate  between  the  anus  and  the  tip  of  the  coccyx,  and 
covered  with  normal  skin.  It  may  attain  the  size  of  a  fetal  head  at 
term,  annoy  the  patient  by  its  size  and  weight,  cause  dyspareunia, 
and  present  a  serious  obstacle  in  the  way  of  childbirth.  Like  simi- 
lar tumors  in  other  localities,  it  may  become  inflamed  and  form  an 
abscess. 

Treatment. — If  it  resists  the  resolvent  action  of  painting  with  tinc- 
ture of  iodine,  it  may  be  emptied  through  a  hydrocele  trocar  and 
injected  with  the  same.  Part  of  the  skin  and  subcutaneous  tissue 
covering  it  may  be  cut  oif,  the  cavity  packed  with  iodoform  gauze,  and 
left  to  fill  by  granulation.  The  whole  tumor  has  also  been  successfully 
extirpated.  If  suppuration  has  occurred,  the  cyst  should  be  freely 
laid  open  from  end  to  end  with  a  bistouiy,  washed  out  with  disinfect- 
ants, and  filled  with  iodoform  gauze. 


PART  III. 

DISEASES  OF  THE  VAGINA. 


CHAPTER  I. 

MALFOEMATIONS.1 

A.  Malformations  of  the  Hymen. 

1.  It  is  doubtful  if  the  hymen  is  ever  absent. 

2.  Atresia  hymenalis  is  the  condition  in  which  the  hymen  forms  an 
imperforate  diaphragm.     It  is  probably  due  to  an  excess  of  growth 
of  the  hymen.     Like  a  transverse  septum  situated  higher  up  in  the 
vagina,  it  prevents  mucus,  cast-off  epithelial  cells,  and  menstrual 
blood  from  flowing  out,  and  causes,  therefore,  an  accumulation  of 
blood  or  mucus  above  it.     Such  an  accumulation  of  blood  in  the 
vagina  is  called  hematocolpos ;  in  the  uterus,  hematometra.     If  the 
blood  is  changed  to  pus,  the  conditions  are  respectively  called  pyocol- 
pos  and  pyometra.     As  a  rule,  the  blood  forms  a  thick,  dark  brown, 
tarry  mass. 

Even  in  young  children  the  closure  of  the  hymen  may  give  rise  to 
a  retention  of  mucus,  forming  a  tumor  which  bulges  out  between  the 
labia  and  obstructs  micturition  and  defecation.  But  much  more 
commonly  it  is  at  the  time  of  puberty  that  the  accumulation  of  men- 
strual blood  causes  pain,  increasing  at  each  menstrual  period,  and 
the  formation  of  a  tumor  gradually  growing  in  size  from  below  up- 
ward. First  the  vagina  is  distended,  then  the  cervix,  the  two  form- 
ing one  globular  mass,  on  the  top  of  which  is  felt  the  undilated  body 
of  the  uterus,  until,  finally,  this  also  takes  part  in  the  dilatation. 
The  tubes  form  sometimes  large  tumors  filled  with  blood  (hematosal- 
pinx),  which  not  always  communicate  with  the  uterus,  the  blood  not 
being  pressed  up  from  the  uterus,  but  coming  from  the  mucous  mem- 
brane of  the  tubes  themselves.  Diverticula  may  bulge  out  from  them. 
They  may  be  divided  into  a  series  of  three  or  four  compartnients  by 
internal  lamella?  growing  from  the  wall  or  by  bands  of  peri  ton  itic 

1  I  have  treated  this  subject  somewhat  more  extensively  in  American  System  of 
Gynecology,  vol.  i.  pp.  257-278. 
326 


DISEASES  OF  THE   VAGINA.  327 

origin,  forming  constricting  rings  without,  and  they  may  be  bound 
to  the  wall  of  the  pelvis  by  strong  adhesions. 

The  tumor  formed  by  the  vagina  and  uterus  may  nearly  fill  the 
pelvic  cavity  and  press  on  the  rectum  and  the  bladder,  causing 
dysuria  and  dyschezia.  The  hymen  becomes  thick  and  fleshy,  as 
do  the  walls  of  the  vagina,  especially  the  muscular  coat,  above  any 
transverse  septum  wherever  located.  It  may  form  a  tumor  in  the 
perineum  as  large  as  the  fetal  head,  which  flattens  out  the  frenulum 
and  is  continuous  with  the  skin  on  the  distended  perineum  and 
labia  of  the  vulva.  In  front  is  found  the  meatus  urinarius.  This 
tumor  is  fluctuating. 

Strangely  enough,  irnperforate  hymen  may  be  found  combined  with 
pregnancy,  which  can  only  be  explained  by  supposing  that  there  has 
been  a  minute  opening,  admitting  spermatozoids,  which  has  closed 
after  menstrual  discharge  had  stopped. 

Diagnosis. — The  bulging  of  the  perineal  region  is  pathognomonic. 
Often  an  occlusion  is  found  at  the  lower  end  of  the  vagina,  just  above 
the  hymen,  but  this  does  not  form  a  tumor  in  the  perineum,  and  on 
close  inspection  the  hymen  with  its  opening  will  be  found  below  and 
in  contact  with  the  occluding  membrane. 

Prognosis. — In  itself,  the  condition  leads  to  rupture  of  the  vagina, 
uterus,  or  tubes,  and  even  operative  interference  is  fraught  with 
danger. 

Treatment. — Spontaneous  rupture  through  the  hymen  being  very 
rare,  and  rupture  of  the  tube  being  much  more  likely  to  occur,  an 
outlet  must  without  delay  be  given  to  the  accumulated  fluid.  The 
operation  consists  in  making  a  crucial  incision  through  the  closed 
hymen  or  in  cutting  it  off  along  its  insertion.  This  may  simply  be 
done  with  knife  or  scissors.  If  the  membrane  is  removed,  it  is  well 
to  stitch  the  edges  of  the  wound  together.  Some  prefer  the  thermo- 
cautery  or  galvano-cautery  for  slitting  open  the  diaphragm,  in  order 
to  protect  the  wound  against  infection.  No  pressure  should  be  exor- 
cised on  the  tumor,  as  it  might  lead  to  rupture  of  the  tubes.  But 
the  uterus  should  be  washed  out  with  a  warm  alkaline  solution  (bicar- 
bonate of  sodium  or  liquor  potassae,  3ss— Oij),  which  dissolves  the 
thick  blood,  and,  after  that  has  been  removed,  with  a  disinfectant. 
Permanent  irrigation  of  the  vagina  has  been  used  as  after-treatment, 
which  prevents  the  entrance  of  air  and  keeps  up  some  degree  of 
pressure. 

If  hematosalpinx  can  be  made  out  before  the  operation,  it  is  best  first  to 
perform  laparotomy,  and  remove  the  distended  tubes  with  the  ovaries ; 
or  vaginal  hysterectomy  and  salpingo-oophorectomy  may  be  preferable. 

Dangers  of  the  Operation. — The  membrane  being  comparatively 
thin  and  of  easy  access,  there  is  no  difficulty  in  incising  or  removing 
it;  but,  simple  as  the  operation  appears,  it  has  more  than  once  proved 


328  DISEASES  OF  WOMEN. 

fatal.  The  two  dangers  are  rupture  of  the  tubes  and  sepsis,  the  latter 
of  which,  being  so  much  more  common,  must  carry  greater  weight  in 
deciding  the  measures  to  be  adopted.  In  regard  to  the  first,  the 
operator  should,  as  stated  above,  abstain  from  pressure,  or  may  per- 
form preliminary  extirpation  of  the  tubes.  In  order  to  avoid  the 
second,  a  large  opening  should  be  made  and  the  accumulated  fluid 
washed  out  immediately.  The  use  of  the  cautery,  sutures,  and  per- 
manent irrigation  is  also  based  on  the  fear  of  sepsis. 

3.  Abnormal    Openings. — Instead   of    having    one    opening,   the 
hymen  may  have  two  placed  side  by  side.     If  the  bridge  between 
them  is  broad,  the  condition  is  called  hymen  bi/oris  or  hymen  bifenes- 
tratus.     If  it  is  narrow,  it  is  called  hymen  septus.     Sometimes  such  a 
partition  grows  out  from  the  anterior  or  posterior  wall  without  reach- 
ing the  opposite  wall,  which  formation  is  called  hymen  subseptus. 

There  may  also  be  many  small  openings,  a  condition  known  as 
hymen  cribriformis. 

4.  Double  Hymen. — The  hymen  may  be  double  in  different  ways. 
One  may  be  placed  above  the  other,  which  probably  is  only  due  to 
the  presence  of  a  transverse  septum  in  the  lower  part  of  the  vagina. 
One  may  also  be  placed  beside  the  other,  the  vagina  itself  being 
double. 

Treatment. — If  the  shape  of  the  hymen  interferes  with  coition  or 
childbirth,  the  condition  is  easily  remedied  by  removing  the  septum, 
making  a  crucial  incision,  or  removing  the  whole  membrane. 

5.  Fleshy  Hymen. — Sometimes  the  hymen  becomes  so  thick  that  it 
is  not  ruptured  in  contact  with  the  penis,  but  constitutes  an  insur- 
mountable obstacle  to  its  entrance  into  the  vagina.     This  may  cause 
considerable  pain,  and  become  a  source  of  much  nervous  irritability 
(vaginismus). 

The  condition  is  easily  remedied  by  cutting  the  offending  part  off 
with  curved  scissors  and  stitching  the  edges  of  the  wound  together. 

B.  Malformations  of  the  Vagina. 

1.  Atresia  and  Stenosis. — The  word  "atresia"  means  a  lack  of 
bore,  and  ought  only  to  be  used  in  speaking  of  a  complete  closure 
of  the  vagina,  whereas  "stenosis"  means  narrowness,  and  may 
properly  be  applied  to  any  condition  in  which  the  vagina  has  not  its 
proper  width.  But  authors  often  use  the  word  atresia  even  when 
there  is  an  opening  in  the  septum  obstructing  the  vagina,  and  then 
divide  atresia  into  complete  and  incomplete. 

The  lower  end  of  the  vagina  may  be  closed  by  a  thin  membrane 
(septum  retrohymenale),  or  one  or  more  solid  transverse  septa  may  be 
found  higher  up  iu  the  vagina,  or,  finally,  there  may  be  a  complete 
absence  of  the  vagina.  In  such  cases  the  uterus  is  commonly  absent 
too,  but  sometimes  a  more  or  less  normal  uterus  may  be  found  beyond 
the  tissue  where  the  vagina  ought  to  be. 


DISEASES  OF  THE   VAGINA.  329 

Complete  vaginal  atresia  gives  rise  to  retention  of  the  menstrual 
flow  and  the  other  conditions  described  above  in  treating  of  atresia 
of  the  hymen.  It  prevents  impregnation,  and,  if  the  septum  is  situ- 
ated low  down,  it  causes  more  or  less  dyspareuuia.  The  pouch  may, 
however,  in  course  of  time,  by  continued  use,  become  considerably 
deeper.  Sometimes  connection  takes  place  in  the  urethra  or  the  rec- 
tum, especially  the  former,  and,  strangely  enough,  such  considerable 
dilatation  causes  only  exceptionally  incontinence  of  urine. 

Much  more  common  than  this  complete  closure  is  the  presence  in 
the  vagina  of  a  transverse  septum  with  one  or  more  openings.  Some- 
times the  opening  is  so  minute  that  it  can  only  be  discovered  at  the 
time  of  menstruation,  when  blood  may  be  seen  trickling  through  it. 
Under  such  circumstances  impregnation  becomes  possible,  and  we 
may,  therefore,  find  labor  obstructed  by  a  transverse  septum  in  the 
vagina,  presenting  an  obstacle  similar  to  that  of  an  imperforate  hymen. 

Different  theories  have  been  proposed  in  order  to  explain  the 
formation  of  transverse  septa  in  the  vagina.  One  is,  that  adhesion 
and  coalescence  have  taken  place  between  opposite  walls  of  the  vagina ; 
another  is,  that  the  Miillerian  ducts  failed  to  be  tunneled  in  the  place 
where  the  diaphragm  is  found  ;  and,  according  to  a  third,  the  vagina 
above  the  septum  is  formed  by  one  of  these  ducts,  and  below  the 
septum  by  the  other. 

A  general  narrowness  of  the  vagina  may  be  due  to  an  arrest  of 
development — a  condition  often  combined  with  an  infantile  uterus — 
and  sometimes  only  one  of  the  Miillerian  ducts  is  developed,  while 
the  other  disappears,  so  that  there  really  is  only  half  a  vagina.  This 
narrowness  may  cause  dyspareunia. 

The  treatment  consists  in  gradual  dilatation  by  means  of  the  bivalve 
speculum  or  plugs  of  glass  or  hard  rubber,  and  the  use  of  lubricants 
in  attempts  at  coition.  This  same  treatment  is  to  be  followed  when 
the  narrowness  is  relative ;  that  is  to  say,  when  the  female  organs  are 
normal,  but  the  husband  has  an  excessively  large  penis. 

So  far,  we  have  only  had  in  view  congenital  conditions,  which  con- 
stitute what  is  called  malformations.  But  similar  septa  may  be 
acquired.  They  may  be  the  result  of  sloughing  and  adhesion  conse- 
quent upon  disease,  or  be  the  result  of  violence,  strong  acids,  or  even 
a  red-hot  iron,  being  applied  in  the  vagina  by  fiendish  wretches. 

Treatment. — The  reader  is  referred  to  all  that  has  been  said  about 
the  dangers  of  imperforate  hymen  and  its  treatment.  But,  besides 
•what  has  been  said  there,  the  transverse  septa  and  the  absence  of  the 
vagina  offer  special  features.  The  thinner  the  septum  is,  the  more 
the  treatment  will  be  like  that  for  imperforate  hymen  ;  the  thicker  it 
is,  the  more  it  approaches  that  for  absence  of  the  vagina,  which  we 
now  shall  consider. 

The  first  thing  to  do  in  a  case  of  absence  of  the  vagina  is  to  make 


330  DISEASES  OF  WOMEN. 

a  thorough  examination,  preferably  under  ether,  by  using  simulta- 
neously a  hand  on  the  abdomen,  a  finger  in  the  rectum,  and  a  cath- 
eter in  the  bladder,  and,  taking  the  presence  or  absence  of  menstrual 
molimina  into  consideration,  to  find  out  whether  the  patient  has  a 
uterus  and  ovaries  or  not.  If  there  is  no  uterus,  no  attempt  should 
be  made  to  make  a  vagina.  It  is  not  only  hardly  justifiable  to  expose 
the  patient  to  the  dangers  of  the  operation  merely  in  the  hope  of 
forming  an  organ  of  copulation,  but  experience  has  shown  that  the 
hope  is  futile.  Where  there  is  no  uterus  the  artificially  formed  vagina 
closes  again.  The  situation  is  entirely  different  if  there  is  a  uterus 
and  the  menstrual  flow  takes  place  internally.  Then  the  operation 
becomes  imperative,  in  order  to  save  the  patient's  life,  and  by  proper 
care  the  new-formed  vagina  may  be  kept  pervious.  If  even  ovaries 
are  present,  impregnation  and  childbirth  may  take  place,  but  would 
be  attended  by  great  danger. 

Modus  Operandi. — The  patient  is  placed  on  her  back  with  her  knees 
drawn  up.  The  vulva  is  stretched  from  side  to  side.  The  mucous 
membrane  is  seized  with  a  tenaculum,  and  a  transverse  incision  made 
midway  between  the  urethra  and  the  anus.  Now  the  operator  works 
his  way  slowly  and  very  carefully  up  between  the  bladder  in  front 
and  the  rectum  behind,  using  a  pair  of  closed  blunt  scissors  and  his 
forefinger  to  tear  the  connective  tissue  between  both,  and  keeping  a 
metal  catheter  in  the  bladder  and  his  left  forefinger  in  the  rectum, 
until  he  reaches  the  os,  which  can  be, felt  from  the  rectum.  He  intro- 
duces the  scissors  through  the  os,  when  the  accumulated  mucus  and 
blood  flow  out.  With  a  dilator  he  stretches  the  cervical  canal  about 
half  an  inch,  washes  out  the  uterus  with  warm  solution  of  bicarbo- 
nate of  sodium  (sj-Oj)  and  after  that  with  creolin  (1  per  cent.). 

A  hollow  glass  plug  (Fig.  219)  in  proportion  to  the  size  of  the  new- 
formed  vagina  is  introduced  into  it,  covered  with  antiseptic  gauze  and 
cotton,  and  held  in  place  by  a  T-bandage.  I  think  it  is  an  improve- 
ment to  have  a  hole  (a)  at  the  bottom  of  the  plug  in  order  to  allow 
escape  of  fluid,  and  one  (6)  on  each  side  of  the  rim  from  which  a 
string  goes  to  the  bandage  surrounding  the  pelvis.1 

The  wound  heals  over  the  plug,  epithelial  cells  growing  out  from 
the  vulva  in  the  course  of  a  month,  during  which  time  the  plug  is 
taken  out  and  cleansed  every  day  and  the  vagina  disinfected.  If 
healing  is  slow,  it  may  be  furthered  by  painting  the  raw  surface  once 
a  day  with  a  weak  solution  of  nitrate  of  silver  (gr.  ij-3j)-  The  patient 
should  wear  the  plug  daily  for  at  least  an  hour  during  a  whole  year, 
but  as  this  is  tiresome  and  hurts  some,  she  is  liable  to  neglect  it,  and 
then  the  canal  shrinks  again  from  the  uterus  downward,  and  it  be- 
comes necessary  to  dilate  it  gradually  or  repeat  the  operation,  which  is 

1  John  Reynders  &  Co.,  cor.  Fourth  ave.  and  Twenty-third  St.,  have  made  such 
plugs  for  me. 


DISEASES  OF  THE   VAGINA. 


331 


still  more  difficult  and  dangerous  than  the  first  time,  when  the  tissue 
yields  more  easily.1 

Other  Methods  for  Keeping  the  Canal  Open. — Instead  of  the  per- 
manent use  of  the  plug,  some  prefer,  after  granulation  is  well  estab- 


FIG.  219. 


Vaginal  Glass  Plug. 

lished — say,  the  end  of  a  month — to  dilate  with  finger  and  speculum 
every  two  or  three  days — a  very  painful  procedure. 

To  cut  out  flaps  of  the  surrounding  skin  and  turn  them  into  the 
new-formed  vagina  is  not  advisable,  on  account  of  the  hairs  growing 
on  these  parts;  but  flaps  of  mucous  membrane  have  been  obtained 
from  the  vulva  and  used  with  success.  Thus,  Kiistner  cut  loose  the 
labia  minora  to  their  posterior  end,  split  them  open  by  a  longitudinal 

1  On  Jan.  25,  1890, 1  operated  on  Annie  K ,  American,  fifteen  and  a  half  years 

old,  for  absence  of  vagina,  combined  with  uterus  unicornis.  She  had  for  some  time 
complained  of  severe  abdominal  pain;  had  a  temperature  of  101°  and  a  pulse  of 
128.  The  hymen  was  normal,  but  the  vagina  was  only  a  quarter  of  an  inch  deep. 
Through  the  abdominal  wall,  the  vagina,  and  the  rectum  was  felt  a  hard,  slightly 
elastic  swelling,  nearly  filling  the  pelvis,  especially  in  the  left  side,  and  extending 
up  into  the  left  iliac  fossa.  1  had  to  form  a  vagina  to  the  full  length  of  my  index- 
finger,  2£  inches,  and  there  was  so  little  tissue  between  the  bladder  and  the  rectum 
that  only  a  thin  transparent  membrane  was  left  between  the  artificial  opening  and 
the  rectum.  There  was  no  cervix,  but  the  os  could  be  felt  far  upward  and  back- 
ward. Finally,  I  succeeded  in  introducing  the  scissors  into  the  os.  A  considerable 
amount  of  thick  yellowish  mucus,  mixed  with  old  blood,  flowed  out.  The  tumor 
diminished,  and  was  washed  out  as  stated  in  the  text.  She  improved  immediately, 
and  made  a  good  recovery,  and  menstruated  three  times  while  she  was  under  my 
observation.  She  was  ordered  to  use  her  glass  plug  one  hour  every  day,  but  so<>n 
got  tired  of  it.  When  I  saw  her  again,  about  a  year  later,  the  upper  half  of  the 
vagina  had  contracted  again  to  the  size  of  a  cervical  canal,  just  admitting  the  sound. 
She  had  a  cyst  in  the  left  iliac  fossa,  without  connection  with  the  genitals,  from 
which  I  evacuated  a  yellowish  clear  fluid.  This  was  thereafter  successfully  treated 
with  injection  of  iodoform  ether,  and  I  have  not  seen  her  since. 


332  DISEASES  OF   WOMEN. 

incision,  and  stitched  them  together  so  as  to  form  a  sac  outside  of  the 
vulva,  which  sac  he  then  stitched  to  the  artificial  canal  formed  between 
the  rectum  and  bladder.  In  another  case  he  successfully  lined  the 
hollow  with  the  mucous  membrane  of  a  part  of  the  resected  intestine 
of  another  patient. 

If  the  atresia  is  only  partial,  the  wound  may  be  covered  by  stitch- 
ing the  edges  of  the  upper  and  lower  segments  of  the  vagina  together.1 

Oophorectomy. — If  absence  of  the  vagina  is  combined  with  absence 
of  the  uterus,  but  active  ovaries  are  present,  causing  menstrual 
molimiua,  the  ovaries  should  be  extirpated  by  laparotomy. 

2.  Double  Vagina. — The  vagina  may  be  divided  by  a  more  or  less 
complete  longitudinal  partition  into  two  halves,  each  of  which  corre- 
sponds to  one  Mulleriau  duct.  Commonly,  but  not  always,  double 
vagina  is  combined  with  double  uterus. 

The  two  halves  of  the  vagina  may  be  unequally  developed,  the 
larger  one  alone  being  used  for  coition.  If  this  one  is  closed  above, 
fecundation  can,  of  course,  not  take  place. 

Instead  of  a  long  partition  there  may  only  be  found  a  more  or  less 
narrow  baud  as  remnant  of  the  original  septum  between  the  Mullerian 
ducts. 

As  a  rule,  a  fully-developed  double  vagina  does  not  give  any 
trouble,  and  is  discovered  accidentally.  If  childbirth  takes  place,  the 
septum  is  more  or  less  completely  torn. 

Treatment. — If  the  septum  interferes  with  coition  or  impregnation, 
it  may  be  split  lengthwise.  Both  halves  are  distended  with  specula 
and  retractors,  so  as  to  put  the  septum  on  the  stretch,  and  then  it  is 
severed  midway  between  the  anterior  and  posterior  walls  by  means 
of  the  thermo-  or  galvano-cautery. 

A  mere  band  oftener  causes  dyspareunia  and  dystocia,  and  may  be 
severed  with  scissors.  If  there  is  any  bleeding,  it  is  checked  by 
cautery,  styptic  cotton,  or  tampon.  If  the  band  is  fleshy,  it  is  prefer- 
able to  tie  near  the  two  ends  and  cut  out  the  middle  piece. 

Double  Vagina  with  Atresia. — Double  vagina  may  be  combined 
with  atresia  on  one  or  both  sides.  If  one  side  is  pervious,  men- 
struation and  impregnation  may  take  place,  and  the  condition  is, 
therefore,  often  overlooked  for  a  long  time.  The  right  half  is  much 
more  liable  to  be  closed  than  the  left.  The  uterus  is  with  few  ex- 
ceptions two-horned. 

Menstrual  molimina,  due  to  retention  in  the  closed  half,  are  pres- 
ent, combined  with  menstrual  flow  through  the  open  half.  The 
tumor  formed  by  the  retained  fluid  bulges  very  much  into  the  latter, 
and  may  distend  the  vulva  and  interfere  with  micturition.  The 
upper  part  of  the  tumor  lies  on  the  side  of  the  uterus.  The  lateral 
atresia  leads  much  more  frequently  to  spontaneous  rupture  than 
1  O.  Kiistner,  Centralblatt  fur  Gynak.,  voL  xvi.  No.  23,  p.  533,  June  10,  1893. 


DISEASES  OF  THE   VAGINA.  333 

atresia  of  the  single  vagina,  and  the  perforation  always  takes  place 
in  the  septum  of  the  cervix  uteri ;  but  this  does  not  effect  a  cure. 
The  contents  are  only  partially  evacuated,  air  and  microbes  enter,  the 
stagnating  fluid  becomes  purulent  or  putrid  (lateral  pyocolpos  and 
pyometra),  and  causes  inflammation  and  ulceration  of  the  walls.  The 
inflammation  may  extend  to  the  tubes  and  the  peritoneal  cavity. 
At  times  the  tumor  increases  again  in  size  until,  after  great  pain,  a 
new  discharge  takes  place  through  the  opening  in  the  septum.  For 
diagnostic  purposes  it  is  of  importance  that  pressure  on  the  vaginal 
tumor  causes  a  purulent  discharge  through  the  os  uteri  of  the  open 
half  of  the  vagina. 

Diagnosis. — Lateral  atresia  has  been  taken  for  hematocele,  but  the 
history  of  a  chronic  disease  with  monthly  exacerbations,  and  the  shape 
and  position  of  the  tumor,  will  help  to  avoid  this  mistake.  In  lat- 
eral atresia  the  tension  of  the  wall  often  varies  at  different  times,  and 
if  it  is  not  very  great  it  is  sometimes  possible  to  invaginate  the  lower 
part  of  the  tumor  and  feel  the  muscular  ring  formed  by  the  os. 

If  the  septum  is  situated  very  high  up,  the  tumor  may  also  be  con- 
founded with  cysts  adherent  to  the  uterus  or  a  myoma  in  the  wall  of 
the  latter.  An  exploratory  puncture  may  become  necessary  to  settle 
the  diagnosis. 

Treatment. — Sims's  speculum  is  introduced  in  the  open  half,  and 
the  septum  slit  open  with  knife,  scissors,  or  preferably  thermo-  or  gal- 
vano-cautery.  In  cases  of  double  atresia  one  side  is  first  opened,  as 
in  atresia  of  the  single  vagina,  and  afterward  the  septum  incised. 

3.  Blind  Canals. — Immediately  above  the  entrance  of  the  vagina, 
laterally,  are  occasionally  found  blind  canals,  which  may  be  an  inch 
and  a  half  long  and  wide  enough  to  admit  the  little  finger.     They  are 
lined  with  smooth  mucous  membrane,  and  are  probably  only  unu- 
sually developed  lacuna?.      They  are  without   practical  importance, 
except  that  they  may  become  receptacles  for  gonococci.     If  the  affec- 
tion cannot  be  cured  with  injections,  it  may  become  necessary  to  lay 
the  canals  open. 

4.  Faulty  Communications. — Familiarity  with  the  history  of  devel- 
opment (p.  31)  allows  us  to  recognize  as  consequences  of  developmental 
arrest  certain  abnormal  conditions  sometimes  met  with.     Thus  we 
have  complete  atresia — i.  e.  absence  of  any  opening  on  the  cutaneous 
surface  leading  into  the  intestinal  or  urogenital  canal,  while  under  the 
skin  is  found  a  common  cloaca  into  which  open  bladder,  vagina,  and 
rectum.     The  next  step  in  development  is  represented  by  cases  where 
this  cloaca  has  an  opening  on  the  surface  of  the  body.     The  rectum 
opens  apparently  into   the   vagina  or  vulva  (atresia   ani   vaginalis 
or  vestibularis.)     It  may  have  a  sphincter  or  not.     In  other  cases  the 
vagina  and  the  urethra  apparently  open  into  the  rectum,  but  in  real- 
ity these  cases  are  only  modifications  of  a  persistent  cloaca. 


334  DISEASES  OF  WOMEN. 

If  the  development  has  been  arrested  still  later,  the  partition  be- 
tween the  rectum  and  the  urogenital  sinus  may  have  been  formed, 
but  the  urethra  seems  to  open  into  the  vagina.  This  is  really  due  to 
a  persistent  urogenital  sinus. 

Complete  atresia  is  only  found  in  non-viable  fetuses.  The  other 
conditions  hardly  ever  become  the  object  of  operative  interference. 
If  the  rectum  opens  into  the  vulva  or  vagina,  an  artificial  anus 
might  be  made ;  but  if  there  is  a  sphincter,  it  might  lose  its  inner- 
vation,  and  the  patient  be  left  in  a  worse  condition  than  she  was 
before.  In  very  rare  cases  there  is  a  normal  anus,  but  a  communica- 
tion between  the  rectum  and  vagina  higher  up — a  congenital  recto- 
vaginal  fistula.  This  may  be  closed  in  the  same  manner  as  the 
acquired  fistula. 

It  is  likewise  very  rare  that  a  ureter  opens  into  the  vagina  instead 
of  the  bladder.  This  may  be  loosened  and  fastened  with  sutures  in 
the  wall  of  the  bladder.1 


CHAPTER   II. 
VAGINAL,  ENTEROCELE. 

VAGINAL  ENTEROCELE,  or  vaginal  hernia,  is  a  tumor  formed  by 
the  intestines,  and  sometimes  the  omentum  or  ovary,  by  inverting  the 
vaginal  wall.  Sometimes  the  protrusion  takes  place  through  an  open- 
ing in  the  muscular  coat  of  the  vagina,  so  that  there  is  a-  hernial  ring, 
and  the  prolapsed  intestine  is  only  covered  by  the  mucous  membrane. 
Commonly  this  protrusion  begins  in  Douglas's  pouch,  but  it  may  also 
occur  between  the  uterus  and  the  bladder,  or  in  the  scar  left  by  vagi- 
nal hysterectomy. 

Causes. — The  hernia  may  be  caused  by  a  fall,  lifting  a  heavy  bur- 
den, straining  at  stool,  but  most  commonly  it  is  due  to  pregnancy 
and  childbirth. 

Symptoms. — In  acute  cases  there  is  a  sudden  pain  and  feeling  of  a 
rupture.  If  the  development  is  chronic,  there  is  a  dragging  sensa- 
tion, constipation,  and  dyspareunia.  No  case  of  strangulation  is 
known,  but  during  childbirth  a  dangerous  pressure  is  exercised  on 
the  tumor  when  it  is  being  pushed  down  in  front  of  the  presenting 
part.  On  examination  is  found  a  pear-shaped,  soft  tumor  protruding 
in  the  lumen  of  the  vagina  or  descending  through  the  vulva.  It 
increases  on  cough,  can  be  pushed  up  into  the  abdominal  cavity,  may 
give  a  gurgling  sound  on  handling,  and,  if  accessible  in  front  of  the 
vulva,  will  give  a  tyrapanitic  percussion-sound.2 

1  W.  H.  Baker  of  Boston,  New  York  Medical  Journal,  Dec.,  1878. 
1  On  account  of  the  great  rarity  of  this  affection  the  following  notes  of  the  only 
case  I  have  ever  met  with  may  be  of  interest :  Elise  V.,  aet  27,  widow,  unipara, 


DISEASES  OF  THE   VAGINA.  335 

Diagnosis. — It  has  been  mistaken  for  a  uterine  polypus — a  mistake 
that  seems  impossible  except  in  consequence  of  unjustifiable  care- 
lessness. It  may  be  much  like  a  vaginal  cyst,  but  this  does  not 
diminish  on  pressure. 

Treatment. — The  intestine  may  sometimes  be  reduced  and  kept  up 
by  some  form  of  pessary,  especially  the  more  bulky  ones,  such  as 
Hoffmann's,  Fowler's,  Garriel's,  or  a  globe-shaped  one  which  will 
be  described  in  treating  of  the  uterus.  Thomas  has  performed  lapa- 
rotomy,  inverted  the  sac,  and  fastened  it  in  the  abdominal  wound. 
Perhaps  colporrhaphy  (p.  340)  may  succeed  in  retaining  the  intes- 
tines in  the  pelvic  cavity.  As  a  last  resort,  the  sac  may  be  opened, 
superfluous  tissue  cut  away,  and  the  edges  united  by  interrupted 
sutures. 

Prolapse  of  the  intestine  into  an  unusually  deep  Douglas's  pouch 
(p.  91)  is  a  somewhat  kindred  condition,  which  may  give  rise  to 
constipation,  a  sensation  of  weight,  and  other  discomfort.  The  intes- 
tine may  perhaps  be  kept  up  by  one  of  the  above-named  bulky 
vaginal  pessaries.  If  this  does  not  succeed  and  the  condition  causes 
considerable  trouble,  an  incision  may  be  made  in  the  posterior  fornix 
and  the  pouch  closed  by  a  continuous  suture  of  catgut. 


CHAPTER    HI. 

PROLAPSE  OF  THE  ANTERIOR  WALL  OF  THE  VAGINA  ; 
CYSTOCELE. 

ANY  part  of  the  vaginal  tube  may  be  pushed  into  its  own  caliber, 
so  as  to  form  a  swelling  there.  We  have  already  mentioned  entero- 
cele,  which  is  the  rarest  of  these  prolapses,  and  in  which  the  intestine 
is  found  in  the  tumor.  Little  less  rare  is  a  bulging  out  of  the  lateral 
walls,  because  these  normally  are  drawn  to  one  side  by  the  attachment 
of  the  levator  ani  muscle  and  bands  of  connective  tissue  interspersed 
with  elastic  fibers  extending  to  the  rami  of  the  pubes  and  the  ischium. 
The  most  common  of  all,  on  the  contrary,  is  a  prolapse  of  the  ante- 
rior wall,  and  on  account  of  the  shortness  and  tightness  of  the  con- 
nective tissue  between  the  vagina  and  the  bladder  this  latter  organ 

of  robust  appearance  and  excellent  constitution,  applied  at  the  German  Dispensary 
on  October  10,  1893.  She  had  been  perfectly  well  until  three  weeks  before  I  saw 
her,  when  she  fell  down  into  a  cellar  and  struck  the  right  side  of  the  abdomen 
against  a  wooden  box.  Since  then  she  had  bloody  discharge  from  the  uterus  and 
abdominal  pain.  By  vaginal  examination  the  uterus  was  found  retroHexed  and 
very  tender,  but  it  could  easily  be  replaced.  In  the  left  and  posterior  wall  of  the 
fornix  was  found  a  soft  elastic  tumor  of  the  size  and  shape  of  a  hen's  egg  and  very 
tender.  It  could  be  partially  pushed  back  into  the  abdominal  cavity,  when  a  sharp 
oval  ring  was  felt  surrounding  it,  probably  an  opening  in  the  pelvic  fascia. 


336  DISEASES  OF   WOMEN. 

always  follows  the  anterior  wall  of  the  vagina  more  or  less  in  its 
descent. 

Causes. — By  far  the  most  common  cause  of  this  displacement  is 
childbirth.  During  pregnancy  all  the  constituent  parts  of  the  vagina 
and  the  surrounding  connective  tissue  grow  and  become  infiltrated 
with  serum.  During  childbirth  these  parts  are  bruised  and  torn. 
During  the  lying-in  period,  and  when  the  patient  gets  up,  the  weight 
of  the  accumulated  urine  presses  on  the  yet  soft  and  yielding  anterior 
vaginal  wall.  If  the  perineum  has  been  ruptured  or  the  vaginal 
ring  is  broken  or  over-distended,  there  is  a  still  greater  lack  of  sup- 
port from  below.  The  increased  weight  of  the  vagina  itself,  due  to 
subinvolntion,  contributes  also  to  the  prolapse. 

Cystocele  may  occur  apart  from  childbirth,  in  consequence  of  excess 
in  venery,  or  even  in  virgins  who  work  hard  and  are  underfed ;  but 
such  cases  are  exceedingly  rare. 

Symptoms. — The  condition  gives  rise  to  frequent  and  often  imper- 
fect micturition.  The  bladder  is  not  entirely  emptied,  and  the 
retained  urine  undergoes  alkaline  decomposition  and  produces  catarrh. 
When  the  patient  lies  on  her  back  with  flexed  and  separated  knees, 
the  anterior  vaginal  wall  is  seen  forming  a  round  swelling  protruding 
through  the  vaginal  entrance.  By  means  of  a  catheter  we  can  easily 
satisfy  ourselves  that  this  swelling  contains  the  base  of  the  bladder. 
If  the  condition  is  complicated  with  procidentia  uteri  (see  below),  the 
bladder  forms  in  front  of  the  uterus,  which  hangs  between  the  thighs, 
a  large  soft  swelling. 

Treatment. — Minor  degrees  of  cystocele  may  be  successfully  treated 
with  astringent  suppositories  or  injections,  by  galvanism,  by  repairing 
a  torn  perineum  and  a  posterior  vaginal  wall,  and  by  a  general  tonic 
regimen.  More  pronounced  cases  call  for  direct  surgical  interference. 
These  operations  are  called  anterior  colporrhaphy.  It  may  be  median, 
lateral,  or  bilateral.  The  median  operation  may  be  performed  accord- 
ing to  Sims's  or  Stolz's  method. 

Sims' 's  Method  (Fig.  220). — The  patient  is  in  the  dorsal  position, 
the  knees  drawn  up  and  separated  by  means  of  Clover's  crutch  or 
Robb's  leg-holder  (p.  198).  The  posterior  wall  is  pulled  down  with  a 
single  Sims  speculum,  a  tenaculum-forceps  is  fastened  in  the  median 
line  just  below  the  point  corresponding  to  the  inner  end  of  the 
urethra,  which  is  marked  by  a  transverse  ridge  (Fig.  143,  p.  166), 
and  another  at  the  lowest  point  near  the  cervix.  The  operator  seizes 
the  mucous  membrane  of  the  anterior  wall  of  the  vagina  somewhere 
near  the  lateral  sulci  with  two  tenacula,  and  draws  them  together. 
Thus  he  ascertains  how  much  tissue  is  redundant,  and  makes  a  snip 
with  a  pair  of  scissors  on  each  side,  in  order  to  mark  the  greatest 
width  of  the  surface  to  be  denuded.  Just  outside  of  these  points  he 
inserts  a  tenaculum-forceps,  so  that  the  whole  surface  to  be  pared  may 


DISEASES  OF  THE   VAGINA. 


337 


be  put  on  the  stretch.  With  a  pair  of  scissors  curved  on  the  flat 
a  strip  of  mucous  membrane  about  £  inch  wide,  and  extending 
from  the  lower  forceps  to  the  upper,  is  cut  off.  Similar  strips 
are  cut  off  parallel  to  the  first  on  the  right  side  until  the  landmark 
is  reached.  Then  the  same  procedure  is  repeated  on  the  left.  In 
this  way  an  elliptical  surface,  with  the  long  axis  in  the  direction 
of  that  of  the  vagina,  is  denuded.  Next  silk  or  silkworm-gut 
sutures  are  inserted  from  side  to  side,  alternatively  deep,  under  the 
whole  surface,  and  superficial,  only  through  the  edges.  It  is  very 
convenient  to  use  irrigation  instead  of  sponges  (pp.  182,  199,  and 
222).  The  sutures  are  removed  from  nine  days  to  four  weeks  after 


FIG.  220. 


f.  ^ 

2 

u                J 

* 

6 


Diagram  of  Sims's  Cystocele  Operation :  A,  denudation  by  cutting  off  longitudinal  strips 
of  mucous  membrane  with  scissors ;  B,  insertion  of  sutures,  alternatively  deep  (1,  3,  5,  7) 
and  superficial  (2,  4,  6). 

the  operation,  according  to  their  accessibility,  which  again  depends 
on  whether  other  operations  are  performed  simultaneously  on  the 
perineum  and  on  the  posterior  wall  of  the  vagina  or  not.  This 
method  leaves  a  linear  cicatrix  in  the  median  line.  Some  prefer 
a  continuous  catgut  suture  inserted  in  superposed  tiers  (p.  221). 

Stolz's  Method  (Fig.  221)  differs  from  Sims's  by  the  circular  shape 
of  the  denuded  surface  and  the  insertion  of  a  purse-string  suture  along 
the  circumference.  The  denudation  is  made  in  exactly  the  same  way. 
For  the  suture  is  used  a  strong  silk  thread  (No.  4  or  5  braided), 
armed  at  both  ends  with  a  medium-sized  curved  needle  without  cut- 
ting edges  except  quite  near  the  point.  One  of  the  needles  is  given 
to  an  assistant ;  the  other  is  seized  with  a  needle-holder,  introduced 
in  the  median  line  (a)  |  inch  behind  the  denuded  surface,  carried  ^ 
inch  to  the  left  under  the  mucous  membrane,  then  made  to  emerge 
£  inch  outside  of  the  denuded  surface  (6),  reintroduced  |  inch  nearer 
22 


338 


DISEASES  OF   WOMEN. 


to  the  meatus,  and  carried  in  the  same  way  alternately  below  and 
above  the  mucous  membrane  at  a  short  distance  from  the  denuded 
surface.  Arriving  a  little  beyond  the  middle  line  (c),  under  the 
meatus  (m),  the  operator  hands  this  first  needle  to  an  assistant,  and 
introduces  the  other  exactly  in  the  same  way  on  the  other  side,  until 
the  whole  denuded  surface  is  surrounded  with  the  thread.  The  two 
ends  are  now  pulled  together,  while  the  assistant  pushes  the  denuded 
surface  back  with  a  uterine  sound.  The  suture  is  tied,  and  the  two 
ends  fastened  with  adhesive  plaster  to  the  abdominal  wall.  Thus 
the  pared  surface  is  brought  together  and  closed  like  a  tobacco-pouch. 

FIG.  221. 


Diagram  of  Stolz's  Cystocele  Operation:  1,  first  needle;  2,  second  needle;  o,  first  point  of 
entrance;  6,  first  point  of  exit;  c,  last  point  of  exit  with  first  needle ;  m,  meatus  urinarius. 

There  is  formed  a  small  puckered  cicatrice,  which  gives  excellent 
support  to  the  bladder. 

The  suture  is  removed  after  nine  or  ten  days  if  of  easy  access ; 
otherwise  it  may  stay  for  weeks. 

Walking's  Method l  is  lateral  or  bilateral.  According  to  its  author, 
laceration  of  the  anterior  vaginal  wall  is  unilateral  or  bilateral.  It 
is  usually  submucous,  and  occurs  at  or  near  the  insertion  of  the  fascia 
into  the  bony  pelvis.  The  location  and  extent  of  the  tear  are  detected 
by  touch  and  by  inspection  of  the  change  in  the  shape  that  occurs  in 
the  anterior  vaginal  wall,  which  normally  presents  a  convexity  cor- 
responding to  the  urethral  curve,  a  marked  concavity  corresponding 
to  the  trigone  of  the  bladder,  and  a  straight  line  or  slight  .convexity 
from  this  point  to  the  uterus. 

1  T.  J.  Watkins  of  Chicago,  111.,  Jour,  of  Gynecology,  Toledo,  O.,  Aug.,  1891,  vol.  L 
No.  5,  p.  305. 


DISEASES  OF  THE   VAGIXA.  339 

For  Watkins's  operation  the  patient  is  placed  in  Sims's  position, 
and  the  anterior  vaginal  wall  exposed  with  his  speculum.  A  point 
of  the  mucous  membrane  to  the  side  of  the  urethra,  near  its  meatus, 
is  caught  with  a  tenaculum.  The  denudation  is  carried  from  this 
point,  along  the  antero-lateral  wall  of  the  vagina,  to  a  point  beyond 
the  prolapse.  This  point  may  be  opposite  the  neck  of  the  bladder, 
or  the  denudation  may  extend  even  as  far  back  as  the  lateral  aspect 
of  the  cervix  uteri.  The  breadth  of  the  denuded  surface  is  dependent 
upon  the  extent  of  the  urethrocele  and  cystocele,  all  the  redundant 
tissue  of  which  it  should  take  in.  The  denudation  is  made  on  one 
or  both  sides  according  as  the  laceration  is  unilateral  or  bilateral. 
Silkworm-gut  sutures  are  passed,  beginning  at  the  uterine  end  of  the 
denudation,  from  side  to  side  in  a  curved  line  which  has  its  convexity 
outward  and  forward.  Each  suture  as  inserted  is  tied,  and  traction 
is  being  exerted  toward  the  cervix  while  the  next  suture  is  being 
introduced  and  tied.  The  sutures  should  include  as  much  connective 
tissue  as  possible,  care  being  taken  not  to  injure  the  bladder,  the 
ureters,  or  the  urethra.  After  passing  the  trigone  of  the  bladder  the 
sutures  should  be  passed  deeply  into  the  lateral  wall  near  its  insertion 
into  the  pubes,  and  as  deeply  into  the  anterior  vaginal  wall  as  the 
increased  thickness  of  the  vesico-vaginal  septum  from  this  point  out- 
ward will  permit.  The  stitches  may  be  removed  after  a  week  or  be 
allowed  to  remain  for  two  or  three  weeks.  It  is  claimed  that  this 
operation  cures  the  incontinence  of  urine  that  sometimes  is  a  distress- 
ing feature  of  cystocele  and  urethrocele.  (Compare  Pawlick's  ope- 
ration for  incontinence,  under  Urinary  Fistula.) 

In  any  of  these  operations  the  bladder  should  be  emptied  every 
four  hours.  If  the  patient  can  urinate,  she  may  be  allowed  to  do  so. 
If  not,  the  urine  is  drawn,  preferably  with  a  soft-rubber  catheter. 
The  patient  should  stay  in  bed  three  weeks. 

Oystopexy. — A  new  French  operation  for  cystocele,  by  which  the 
anterior  wall  of  the  bladder  is  fastened  to  the  abdominal  wall,  has 
been  performed  several  times  with  success.  The  bladder  is  injected 
with  five  ounces  of  solution  of  boracic  acid.  A  transverse  incision 
2£  inches  long  is  made  through  the  abdominal  wall  in  the  hypogastric 
region.  Two  catgut  sutures  are  carried  through  the  lower  edge  of 
the  wound  except  the  skin,  then  through  the  outer  layers  of  the 
anterior  wall  of  the  bladder,  and  through  the  upper  edge  of  the 
wound.  After  tying  these  sutures  the  skin  is  stitched  together. 
During  the  first  six  days  the  catheter  is  used  twice  a  day  only. 


340  DISEASES  OF  WOMEN. 

CHAPTER  IV. 

PROLAPSE  OF  THE  POSTERIOR  VAGINAL  WALL;  RECTOCELE. 

NEXT  to  the  prolapse  of  the  anterior  wall,  that  of  the  posterior  is 
the  most  common  form  of  prolapse  of  the  vagina.  It  is  commonly 
called  "  rectocele,"  but  this  name  is  only  used  correctly  if  the  pro- 
lapse contains  the  rectum,  which,  as  a  rule,  is  not  the  case.  The  con- 
nective tissue  between  the  rectum  and  the  vagina  being  much  longer 
and  looser  than  that  between  the  bladder  and  the  vagina,  the  latter  slides 
away  from  the  rectum,  doubles  up,  and  forms  a  round  swelling  bulging 
out  through  the  vaginal  entrance.  By  pinching  this  fold  and  by  intro- 
ducing a  finger  into  the  rectum  we  can  easily  satisfy  ourselves  that 
this  is  so.  But  in  the  course  of  time  the  anterior  rectal  wall,  lacking 
its  normal  support  in  front,  may  become  distended  and  form  a  pouch 
descending  inside  of  that  formed  by  the  vagina. 

Etiology. — The  causes  are  similar  to  those  enumerated  for  cysto- 
cele,  except  the  weight  of  the  bladder,  for  which  here  is  substituted 
constipation. 

Symptoms. — The  symptoms  are  a  similar  dragging  sensation.  Con- 
stipation, besides  being  a  cause  of  rectocele,  is  a  sequence  of  it,  and 
may  lead  to  proctitis  with  ulceration  of  the  mucous  membrane.  When 
the  patient  lies  on  her  back  with  separated  knees,  a  globular  swelling, 
formed  by  the  posterior  wall  of  the  vagina,  is  seen  protruding  through 
the  vaginal  entrance — a  swelling  that  increases  in  size  when  she  bears 
down  or  stands  on  her  feet. 

Treatment. — Posterior  colporrhaphy  consists  in  the  denudation  on 
the  posterior  wall  of  an  elliptic  surface  similar  to  that  described  in 
treating  of  Cystocele,  but  is  seldom  resorted  to.  A?  a  rule,  the  peri- 
neum and  the  vaginal  entrance  have  been  injured,  and  the  operation 
called  for  is  Hegar's  or  Emmet's  colpoperineorrhaphy.  (See  pp.  311 
and  316.) 

Vaginal  Prolapse  and  Inversion. — When  the  whole  vagina  sinks 
down  all  around,  the  condition  is  particularly  called  prolapse  of  the 
vagina,  and  if  this  goes  so  far  that  the  whole  tube  is  turned  inside  out 
and  forms  a  sausage-shaped  mass  hanging  between  the  thighs  and  sur- 
rounding the  prolapsed  uterus  and  bladder,  and  sometimes  the  rectum, 
it  is  called  inversion. 

The  mucous  membrane,  exposed  to  the  air,  becomes  dry  and  scaly, 
and,  on  the  other  hand,  the  thrown-oif  epithelial  cells,  if  the  parts 
are  not  kept  clean,  form  a  white,  malodorous  smegma  in  the  pouch  be- 
tween the  prolapse  and  the  perineum,  which  irritates  the  mucous  mem- 
brane and  gives  rise  to  vaginitis.  This  condition  is  connected  with 
prolapse  of  the  uterus,  and  will  be  considered  in  treating  of  that  disease. 


DISEASES  OF  THE   VAGINA.  341 


CHAPTER   V. 

INJURIES;  THROMBUS  OR  HEMATOMA. 

THE  tear  in  the  hymen  produced  by  the  first  coition  may  cause  a 
severe  and  even  fatal  hemorrhage.  If'  an  artery  is  found  spurting, 
it  must  be  tied.  In  other  cases  an  application  of,  or  injection  with, 
liquor  ferri  will  suffice  to  check  the  hemorrhage  (pp.  170  and  172). 
In  order  to  prevent  its  recurrence  the  tear  should  be  given  time  to 
heal,  and  some  vaseline  applied  before  intercourse  until  the  vaginal 
entrance  is  dilated. 

Much  more  serious  are  the  tears  in  the  vagina  that  occur  under 
similar  circumstances.  The  wall  has  been  found  torn  from  the  vagi- 
nal entrance  to  the  fornix.  Tears  are  also  occasionally  produced  dur- 
ing coition  with  women  who  have  had  frequent  intercourse  or  even 
borne  children,  but  then  there  is  a  strong  suspicion,  sometimes  cor- 
roborated by  confession,  that  some  hard  object  has  been  introduced 
simultaneously  with  the  penis.  Such  a  tear  may  also  be  caused  by 
coition  with  old  women  where  senile  atrophy  has  taken  place,  or 
with  women  afflicted  with  stenosis  or  atresia  of  the  vagina  or  double 
vagina.  Transverse  tears  of  the  fornix  have  occurred  during  coition 
after  the  operation  for  lacerated  perineum.  In  such  cases  it  is  prob- 
ably due  to  the  shortening  of  the  posterior  wall.  Sometimes  the 
lesion  is  due  to  unusual  postures  during  the  act. 

During  childbirth  the  vagina  is  quite  frequently  torn.  In  most 
cases  the  lesion  extends  only  through  the  thickness  of  the  mucous 
membrane,  and  is  then  of  little  importance,  but  it  may  penetrate 
through  the  whole  thickness  of  the  wall  into  the  surrounding  con- 
nective tissue.  In  regard  to  these  lesions  the  reader  is  referred  to 
•works  on  obstetrics. 

The  vagina  may  also  be  injured  by  falls  on  a  pointed  object,  by 
attacks  of  horned  animals,  etc.,  or  by  obstetrical  and  surgical  opera- 
tions, especially  the  extraction  of  the  child  by  means  of  the  forceps, 
the  replacement  of  an  inverted  uterus,  or  the  removal  of  a  large 
uterine  fibroid.  Even  a  fall  with  the  abdomen  against  the  sharp 
edges  of  a  step  on  a  staircase  has  indirectly  caused  a  tear  of  the  mucous 
membrane  of  the  vagina.1 

Symptoms. — These  tears  are,  of  course,  accompanied  by  consider- 
able pain.  They  may  cause  severe  hemorrhage.  Sometimes  the  intes- 
tine prolapses  and  may  become  gangrenous,  leaving  an  ileo- vaginal 
fistula.  There  may  also  remain  an  opening  into  the  peritoneal  cavity, 
through  which  the  intestine  can  slip  out  and  be  brought  back.  All 

1  Centralbl.jur  Gynak.,  1892,  No.  31,  xvi.  p.  614. 


342  DISEASES  OF  WOMEN. 

the  symptoms  of  septicemia  may  be  developed.  A  permanent  recto- 
or  vesico- vaginal  fistula  may  remain. 

Prognosis. — With  proper  surgical  help  the  prospects  are  good. 

Treatment. — The  vagina  is  cleaned  of  clots,  spurting  arteries  tied 
with  catgut,  the  edges  of  the  wound  united  with  sutures,  and  a  few 
pledgets  of  iodoform  gauze  placed  over  the  wound.  These  are  re- 
newed about  every  three  days. 

Thrombus  or  hematoma  is  a  swelling  formed  by  the  extravasation 
of  blood  under  the  mucous  membrane.  It  is  nearly  always  due  to 
childbirth,  and  the  reader  is,  therefore,  referred  to  works  on  obstetrics 
for  information  concerning  it. 


CHAPTER    VI. 
FOREIGN  BODIES. 

FOREIGN  BODIES  are  by  no  means  rare  in  the  vagina.  Most  com- 
monly they  are  objects  used  by  the  patient  herself  in  masturbating  or 
as  preventives  of  conception.  Sometimes  they  have  been  placed  there 
for  therapeutic  purposes  by  a  physician  or  a  midwife.  In  rare  cases 
their  introduction  is  due  to  brutal  jokes  or  acts  of  vengeance. 

The  most  diverse  objects,  such  as  pessaries,  sponges,  hairpins,  sticks, 
needle-cases,  snuff-boxes,  glasses,  pomade-jars,  bottles,  etc.,  have 
been  introduced  and  remained  for  months  or  years  in  the  vagina. 
Intestinal  worms  and  insects  have  found  their  way  to  the  same  place. 

Symptoms. — According  to  their  size,  shape,  and  length  of  sojourn 
foreign  bodies  may  give  rise  to  a  great  variety  of  symptoms.  The 
patient  complains  of  pain  in  the  pelvis,  the  hypogastric  and  the  lum- 
bar regions,  or  shooting  down  along  the  inside  of  the  thighs.  A 
purulent  and  offensive  discharge,  dysuria,  dyschezia,  and  dyspareunia 
are  developed.  The  presence  of  the  foreign  body  may  cause  ulcera- 
tion ;  gangrene ;  fistulous  communications  between  the  vagina  and  the 
urethra,  the  bladder,  or  the  rectum  ;  peritonitis  ;  and  pelvic  abscess. 

Diagnosis. — Often  the  patient  has  forgotten  the  origin  of  her 
trouble  or  is  restrained  by  shame  from  telling  it.  Besides  a  vaginal 
examination  with  finger  and  speculum,  often  the  examination  through 
the  rectum  or  with  catheter  or  finger  in  the  bladder  may  be  of  great 
help  in  arriving  at  a  diagnosis.  The  object  may  change  much  in 
shape  by  the  deposit  of  calcareous  matter  around  it.  It  may  become 
entirely  hidden  from  view  by  burrowing  into  the  tissues,  which  close 
over  it,  or  migrate  into  the  abdominal  cavity.  A  sponge  giving  rise 
to  hemorrhage  and  a  foul  discharge  has  more  than  once  been  taken 
for  a  carcinomatous  cervix. 

Treatment. — The  treatment  consists  in  the  removal  of  the  foreign 


DISEASES  OF  THE   VAGINA.  343 

body  and  in  combating  the  inflammation  and  other  disorders  caused 
by  its  presence.  While  the  first  indication  in  most  cases  is  simple 
enough  to  fulfil,  in  others  all  the  ingenuity  of  a  surgical  mind  and 
the  resources  of  a  good  armamentarium  are  required.  As  a  rule,  the 
object  can  be  removed  through  the  vulva,  but  in  exceptional  cases  it 
has  been  found  advantageous  to  withdraw  it  through  the  rectum  or 
the  bladder.  Lengthy  objects  occupying  a  transverse  position  must 
be  seized  near  one  of  the  ends.  Large  objects  must  sometimes  be 
broken  with  shears  or  lithotriptic  instruments.  Considerable  help 
is  often  afforded  by  introducing  a  finger  into  the  rectum  and  hooking 
it  over  the  body  from  above.  In  regard  to  hairpins,  it  must  be 
remembered  that  they  almost  invariably  are  introduced  with  the  ends 
pointing  downward  to  the  vulva,  which  ends  must  be  freed  before 
the  pin  can  be  extracted.  Sometimes  an  incision  must  be  made  to 
reach  the  body.  If  the  vagina  contains  pieces  of  broken  glass  with 
sharp  edges,  the  walls  should  be  lubricated  and  plaster  of  Paris  poured 
in,  which  will  settle  around  the  pieces  and  form  one  mass  with  them 
that  may  be  withdrawn  without  cutting  the  vagina.1 

The  second  indication  will  in  most  cases  be  met  by  using  antiseptic 
and  astringent  vaginal  injections.  Sometimes  a  consecutive  eudo- 
metritis  calls  for  treatment,  and  in  rare  cases  fistula  operations,  or 
even  laparotomy,  may  be  required. 


CHAPTER  VII. 
YAGINITIS. 

VAGINITIS  is  the  word  commonly  used  in  America  to  designate 
inflammation  of  the  vagina,  but  as  the  suffix  -itis  is  of  Greek  origin 
and  vagina  Latin,  exception  has  been  taken  to  it.  German  authors 
have  substituted  the  term  colpitis,  and  English  sometimes  use  elytritis. 

Under  the  term  "  vaginitis  "  are  comprised  so  very  different  con- 
ditions that  it  is  necessary  to  admit  certain  divisions  and  subdivisions 
of  the  subject,  which  is  done  in  many  different  ways  by  different 
authors  choosing  different  standpoints. 

Thus  we  distinguish  between  acute  and  chronic  vaginitis,  the  differ- 
ence being  not  only  limited  to  the  time  the  disease  lasts,  but  also  to 
the  greater  and  lesser  intensity  of  the  symptoms.  The  acute  form 
commonly  ends  in  less  than  a  month ;  the  chronic  has  no  definite 
limit. 

A  vaginitis  is  called  primary  when  it  appears  first  in  the  vagina; 
secondary  if  the  inflammation  invades  this  organ  from  another  part 

1  R.  J.  Levis  of  Philadelphia. 


344  DTSEASES  OF  WOMEN. 

of  the  body,  especially  the  vulva,  the  uterus,  the  rectum,  or  the 
urethra. 

In  regard  to  the  chief  feature  of  the  disease  we  distinguish  between 
catarrhal  vaginitis,  characterized  by  a  discharge  from  the  mucous 
membrane ;  exudative  vaginitis,  in  which  a  solid  inflammatory  exu- 
dation takes  place  either  on  the  surface  of  the  mucous  membrane 
(croupous  vaginitis)  or  in  the  depth  of  the  same  (diphtheintic  vaginitis) ; 
and  phlegmonous  vaginitis,  also  called  dissecting  vaginitis  or  peri- 
vaginitis,  in  which  the  inflammation  has  its  seat  in  the  connective 
tissue  surrounding  the  vagina,  and  leads  to  the  severance  and  expul- 
sion of  the  whole  tube. 

As  subdivisions  we  unite  under  the  term  "  catarrhal"  the  following 
forms  of  vaginitis  :  1,  the  granular  (also  called  follicular,  or  glandu- 
lar) ;  2,  the  simple  ;  3,  the  adhesive ;  4,  the  gonorrheal ;  5,  the  exfoli- 
ative;  and  6,  the  emphysematous  vaginitis.  To  the  diphtheritic 
vagiuitis  belongs  the  dysenteric. 

A.  Catarrhal  Vaginitis. — Pathological  Anatomy. — In  granular 
vaginitis  the  epithelium  as  a  whole  becomes  thicker,  the  papilla?  be- 
come larger,  and  circumscribed  groups  of  small  round  cells  are  formed 
under  them  and  send  proliferations  into  them.  When  the  papilla? 
increase  in  length  and  width,  the  epithelial  cover  immediately  over 
them,  and  the  tongues  it  sends  in  between  them  become  thinner ;  at 
the  same  time  the  blood-vessels  are  much  developed.  These  cell- 
groups  and  the  swollen  papillae  on  their  top  form  on  the  surface  of 
the  vagina  circular  prominences  as  large  as  lentils. 

In  simple  catarrhal  vaginitis  a  similar  process  takes  place  on  a 
smaller  scale,  so  that  the  cell-groups  and  the  swollen  papilla?  remain 
under  the  level  of  the  epithelium.  In  the  chronic  form  pigment  is 
imbedded  in  the  deeper  cells  of  the  epithelium. 

The  adhesive  form  is  especially  found  in  old  women,  but  clinically 
a  similar  condition  is  also  observed  in  young  children.  The  vagina 
is  spotted  or  striped,  being  the  seat  of  ecchymoses  and  superficial 
ulcerations,  and  there  is  great  tendency  to  coalescence  between  the 
surfaces  lying  in  contact  with  one  another.  The  microscope  reveals 
similar  cell-groups  under  the  surface  as  in  the  two  other  forms,  but 
here  the  whole  epithelial  layer  is  lost  over  the  infiltrated  spots. 

In  the  discharge  is  commonly  found  an  infusorial  animalcule  called 
Trichomonas  vaginalis.  Even  in  the  secretion  of  the  normal  vulvo- 
vaginal  tract  in  children  there  are  found  epithelial  cells,  in  some  quite 
a  number  of  pus-cells,  numerous  bacteria,  cocci,  diplococci,  bacilli, 
and  spirilla,  but  never  the  gonococcus  of  Neisser,  which  is  pathogno- 
monic  of  gonorrhea.  It  is  a  diplococcus  found  in  the  interior  of  the 
epithelial  cells  and  of  pus-corpuscles,  and  is  characterized  by  becoming 
decolorized  by  Gram's  method.1 

1  Gram's  Method. — The  cover-glass  smeared  with  the  substance  to  be  examined  is 


DISEASES  OF  THE   VAGINA.  345 

Etiology. — Old  women  are  liable  to  have  vaginitis  without  any 
other  particular  cause  than  their  age.  Young  children  often  suffer 
likewise  from  vaginitis,  due  to  the  accumulation  of  old  epithelial  cells 
in  the  vagina,  whence  they  do  not  easily  escape  on  account  of  the 
smallness  of  the  opening  in  the  hymen.  The  great  afflux  of  blood 
and  formation  of  new  tissue  that  take  place  in  pregnancy  lead  very 
frequently  to  it.  Even  menstruation  is  liable  to  cause  it,  or  make  it 
worse  if  already  present.  Anemia  and  scrofula  predispose  to  it. 
Often  it  accompanies  eruptive  fevers,  especially  measles.  Direct 
causes  are  exposure  to  cold,  especially  sitting  on  a  cold  stone ;  exces- 
sive coition,  masturbation,  or  rape ;  the  presence  of  foreign  bodies, 
especially  pessaries ;  the  use  of  too  hot  or  too  strong  injections ;  opera- 
tive interference ;  the  irritation  caused  by  urine  or  fecal  matter  enter- 
ing the  vagina  through  fistula?,  or  by  an  acrid  discharge  coming  down 
from  the  uterus  or  from  a  pelvic  abscess.  The  most  common  cause 
by  far  of  the  acute  form  is  infection  with  gonorrheal  discharge  in 
whatever  way  the  infecting  principle  may  enter  the  vagina. 

Symptoms. — The  patients  have  a  disagreeable  sensation  of  heat  in 
the  vulva  and  the  vagina.  They  have  pain  in  the  pelvis  and  the 
groins,  which  increases  by  walking  or  any  other  exercise.  They  com- 
plain of  general  malaise,  and  are  often  feverish.  Micturition  is  ac- 
companied by  a  burning  sensation.  Defecation  may  also  be  painful. 
The  vagina  is  so  tender  to  the  touch  that  the  introduction  of  a  specu- 
lum causes  great  pain,  and  sexual  intercourse  becomes  impossible. 
The  mucous  membrane  is  red  and  swollen.  At  first  it  is  dry,  but 
in  a  day  or  two  a  discharge  begins,  which  first  is  mucoid,  then  muco- 
purulent,  and  finally  consists  of  thick  creamy  pus.  The  vaginal  por- 
tion presents  a  deep  red  areola  around  the  os,  which  easily  bleeds  on 
being  wiped,  and  a  plug  of  thick  muco-purulent  matter  is  seen  in  the 
cervical  canal.  By  pressing  on  the  urethra  a  drop  of  pus  is  commonly 
brought  out.  The  inflammation  is  apt  to  remain  long  in  the  upper 
part  of  the  vagina.  Sometimes  it  spreads  to  the  vulvo-vaginal  or  the 
inguinal  glands,  where  it  may  end  in  resolution  or  induration,  or 
cause  the  formation  of  an  abscess.  At  the  menstrual  periods  the 
symptoms  of  vaginitis  are  apt  to  become  more  marked,  and  a  decided 
exacerbation  is  caused  by  pregnancy  and  childbirth. 

In   chronic   catarrhal  vaginitis   the    symptoms    have    much    less 

passed  quickly  through  the  flame,  and  placed  from  two  to  three  minutes  in  a  solution 
of  gentian  violet,  prepared  according  to  the  following  formula:  to  10  cc.  of  water  add 
2  cc.  aniline  oil,  shake  well,  and  filter  through  moist  filter-paper.  To  the  clear  ani- 
line water  obtained  add  1  ec.  of  97  per  cent,  alcohol  and  1  cc.  of  a  saturated  alco- 
holic solution  of  gentian  violet.  The  excess  of  fluid  is  drained  off  from  the  cover- 
glass  with  filter-paper.  Next,  the  cover-glass  is  placed  for  five  minutes  in  Grams 
iodine  solution,  which  consists  of  iodine,  1  part ;  iodide  of  potash,  2 ;  water,  300 ;  and 
then  placed  directly  into  alcohol,  97  per  cent.,  in  order  to  wash  out  all  the  coloring 
matter.  (Henry  Heiman,  "  A  Clinical  and  Bacteriological  Study  of  the  Gonococcus 
(Neisser),"  New  York  Medical  Record,  June  22,  1895.) 


346  DISEASES  OF  WOMEN. 

intensity.  The  patient  may,  however,  complain  -of  a  sensation  of 
heaviness  or  smarting.  The  chief  symptom  is  the  discharge,  which 
sometimes  is  more  purulent,  in  other  cases  more  mucoid.  The  vagina 
is  of  a  dark  red,  bluish,  or  grayish  color,  and  often  the  seat  of  ero- 
sions. The  mucous  membrane  is  thickened,  folded,  and  often  more 
or  less  prolapsed. 

Vaginitis  may  have  the  chronic  type  from  the  beginning,  or  the 
chronic  may  be  a  continuation  of  the  acute  form.  Gonorrheal  vagi- 
nitis  is  particularly  liable  to  become  chronic,  because  the  infecting 
element  is  retained  in  the  urethral  ducts,  the  ducts  of  the  vulvo- 
vaginal  glands,  or  the  small  vestibular  glands. 

The  chronic  form  is  often  secondary,  due  to  an  irritating  discharge 
trickling  from  the  uterus,  or  of  constitutional  origin  in  scrofulous  or 
chlorotic  women.  It  is  a  frequent  accompaniment  of  old  age,  and  is 
quite  common  during  pregnancy. 

Diagnosis. — The  signs  of  vaginitis  are  so  distinct  that  the  disease 
is  easily  recognized.  Still,  the  physician  must  be  on  his  guard  in 
order  not  to  mistake  for  vaginitis  a  discharge  from  the  interior  of  the 
womb  due  to  endometritis,  cancer,  fibroma,  or  other  affections  of  the 
uterus,  or  a  pelvic  abscess  discharging  its  contents  through  a  fistulous 
tract  into  the  vagina. 

The  differential  diagnosis  between  gonorrheal  and  simple  non-viru- 
lent catarrh  is  of  great  importance,  both  as  to  treatment  and  from  a 
medico-legal  standpoint,  but  science,  as  a  rule,  does  not  warrant  us 
in  going  beyond  a  diagnosis  of  probability  in  this  respect.  We  try 
to  obtain  the  history  of  the  case.  Very  often  the  mere  behavior  of 
the  patient  furnishes  already  a  strong  suspicion  that  her  conscience 
is  burdened  with  guilt,  and  by  following  this  hint  the  physician  may 
be  able  to  elicit  a  confession.  Sometimes  it  is  possible  to  examine 
the  man  who  is  the  source  of  the  infection.  The  presence  of  purulent 
ophthalmia  in  children  of  the  family  makes  the  gonorrheal  nature 
of  the  vagiuitis  probable,  the  germs  of  the  disease  having  been  carried 
to  the  children  by  fingers,  sponges,  towels,  etc.  On  the  other  hand, 
the  presence  of  a  gonorrheal  vaginitis  in  a  child  may  be  traced  to  the 
same  disease  in  the  mother  or  other  female  member  of  the  household, 
and  thereby  an  innocent  man,  who  is  accused  of  rape,  saved  from 
unmerited  punishment,  There  is  no  feature  in  the  disease  itself  that 
with  absolute  certainty  can  serve  to  prove  whether  it  is  of  gonorrheal 
origin  or  not.  Severe  cases  of  common  catarrhal  vaginitis  produce  a 
pus  that  is  contagious.  Certain  circumstances,  however,  are  more 
frequently  found  in  gonorrhea  than  in  non-specific  catarrh.  The 
mucous  membrane  is  of  a  particularly  bright  red  color ;  the  discharge 
consists  of  thick  creamy  pus ;  as  a  rule,  the  cervical  canal  aind  the 
urethra  are  implicated  ;  there  is  greater  tendency  to  inflammation  of 
Bartholin's  glands;  the  development  of  vegetations,  if  the  patient  is 


DISEASES  OF  THE  VAGINA.  347 

not  pregnant,  speaks  also  in  favor  of  the  specific  nature  of  the  case. 
The  presence  of  recent  tears  and  bruises  may  be  of  great  importance 
as  evidence  of  rape,  in  which  connection  it  may  be  worth  mentioning 
that,  unfortunately,  there  reigns  a  wide-spread  superstition  among 
uncultivated  men  that  a  gonorrhea  is  cured  by  connection  with  a 
virgin,  which  often  leads  to  assaults  upon  little  girls. 

The  most  conclusive  proof  is  thought  to  be  the  presence  of  gonococci, 
but  there  are  as  yet  so  great  differences  between  the  views  of  bacteriolo- 
gists on  this  subject,  that  it  would  be  unjustifiable  to  base  on  the  bacteri- 
ological investigation  alone  an  assertion  which  may  cause  the  conviction 
of  an  innocent  man  accused  of  rape  or  east  the  opprobrium  of  infidelity 
on  a  faithful  wife.  From  a  clinical  standpoint  we  must  say  there  is 
always  doubt  as  to  the  specific  or  non-specific  nature  of  vaginal 
catarrh,  and  therefore,  when  called  upon  to  give  an  opinion  as  experts, 
we  must  give  the  accused  the  benefit  of  the  doubt.  I  have  seen  cases 
of  urethritis  followed  by  epididymitis  where  it  was  as  sure  as  any 
human  thing  can  be  that  neither  husband  nor  wife  had  worshiped 
strange  gods,  and  I  have  also  seen  a  newly-married  girl,  of  good 
family,  set.  17,  get  all  symptoms  of  gonorrhea,  inclusive  of  salpingitis, 
although  the  husband  was  examined  by  a  prominent  andrologist,  who 
declared  there  were  no  gonococci,  but  many  other  kinds  of  cocci,  in 
his  urethra. 

Prognosis. — Non-virulent  catarrhal  vaginitis  is,  as  a  rule,  not  a 
dangerous  disease.  The  acute  form  yields  readily  to  treatment :  the 
chronic  form  may  be  protracted  through  years.  Gonorrheal  vaginitis 
is  a  much  more  serious  disease  than  gonorrhea  in  men.  It  is  true 
that  urethritis,  on  account  of  the  wideness,  shortness,  and  compara- 
tively straight  course  of  the  canal  is  cured  more  easily  than  in  men, 
even  without  treatment,  the  mere  gush  of  urine  serving  the  purpose 
of  a  thorough  cleansing.  But,  on  the  other  hand,  the  disease  is  apt 
to  linger  in  the  folds  of  the  vagina,  in  the  deep  depressions  of  the 
plica?  palmatae,  in  the  cervical  canal,  in  Bartholin's  glands,  in  the 
urethral  ducts,  and  in  the  smaller  vestibular  glands,  so  that  it  is 
hardly  possible  to  prognosticate  its  duration.  If  it  extends  up  through 
the  uterus  and  the  tubes  to  the  peritoneal  cavity,  it  becomes  not  only 
a  disease  hard  to  cure,  and  sometimes  calling  for  capital  operations, 
but  it  jeopardizes  of  itself  the  life  of  the  patient.  Even  in  children 
it  has  become  necessary  to  remove  the  appendages  of  the  uterus  on 
account  of  pyosalpinx  due  to  gonorrhea.  Apart  from  the  danger  to 
life  and  health,  it  is  apt  to  cause  sterility  by  closure  of  the  tubes  or 
by  imbedding  the  ovaries  in  exudative  inflammatory  masses.  If  the 
woman  conceives  and  gives  birth  to  a  child,  the  chances  of  catching 
puerperal  infection  are  much  increased,  probably  because  the  presence 
of  gonococci  facilitate  the  development  of  pyogenic  microbes. 

Treatment. — Patients  affected  with  severe  acute   vaginitis   should 


348  DISEASES  OF  WOMEN. 

stay  in  bed  for  eight  or  ten  days,  or  at  least  lie  quietly  on  a  lounge. 
They  should  l>e  given  a  saline  aperient.  Their  diet  should  be  bland 
in  quality  and  moderate  in  amount.  Vaginal  injections  of  plain  hot 
water  should  be  given,  and  in  order  to  reach  all  the  recesses  of  the 
vagina  it  is  best  to  stretch  it  by  means  of  a  wire  speculum — e.  g. 
Blakeley's  resilient  speculum.  If  the  tenderness  is  so  great  that  no 
instrument  can  be  introduced,  much  relief  is  experienced  by  frequent 
hot  alkaline  affusions  of  the  external  genitals  (borax  or  bicarbonate  of 
soda  3j  to  Oj,  with  addition  of  tinct.  opii  3j).  To  the  water  used  for 
injection  may  be  added  emollient  or  aromatic  substances,  such  as  lin- 
seed meal  or  chamomile  flowers.  When  the  pain  and  tenderness  sub- 
side and  the  discharge  diminishes,  bichloride  of  mercury  (1  :  5000)  or 
chloride  of  zinc  (1  :  100)  are  used:  In  pregnant  women  it  is  better, 
on  account  of  the  risk  of  mercurial  poisoning,  to  avoid  the  corrosive 
sublimate,  and  use  creolin  or  permanganate  of  potassium  (1  per  cent.) 
instead.  Still  later  it  is  well  to  paint  the  affected  part  of  the  vagina 
with  nitrate  of  silver  in  substance  or  in  a  strong  solution  (3ss-.lj) 
twice  a  week.  If  the  uterus  is  affected,  that  should  be  treated  sepa- 
rately. If  it  is  not,  a  tampon  of  absorbent  gauze  with  astringent 
substances  mixed  with  glycerin,  such  as  subnitrate  of  bismuth  (1  :  4), 
boroglyceride  (1  :  16),  tannin  (1:8,  see  p.  178),  is  introduced,  and 
changed  every  day.  lodoform  gauze  has  also  a  very  good  effect,  but 
has  an  offensive  and  tell-tale  odor.  After  the  nitrate  of  silver  has  been 
used  several  times,  powdered  boracic  acid  may  be  introduced  through 
a  speculum  into  the  fornix  vaginaB,  and  retained  by  means  of  a  tampon. 

Antibknnoi-rhagic  drugs  (oL.santali,  bals.  copaiva?,  and  cubebs)  are 
less  well  borne  by  women  than  by  men,  and  should,  therefore,  be  given 
in  somewhat  smaller  doses.  They  should  only  be  used  in  the  sub- 
acute  and  chronic  stages. 

In  chronic  vaginitis  astringent  injections  and  applications  are  used. 
Extr.  pini  Canadensis,  used  on  tampon,  is  praised.  For  chronic 
urethritis  small  rods  made  of  iodoform  and  cacao-butter  are  intro- 
duced and  squeezed  against  the  walls.  If  the  gonorrheal  poison 
lurks  in  glands  and  ducts,  these  must  be  slit  open,  touched  with  pure 
carbolic  acid,  and  dressed  with  iodoform  gauze.  For  further  infor- 
mation the  reader  is  referred  to  the  chapter  on  Leucorrhea  (p.  250). 

Exfoliative,  or  Epithelial,  Vaginitis  is  a  rare  disease.  It  is  mostly 
combined  with  exfoliative  endometritis  (membranous  dysmenorrhea) 
and  found  in  hysterical  women.  The  vagina  shows  the  usual  changes 
due  to  catarrh.  Membranes  as  much  as  an  inch  in  diameter,  and  con- 
sisting of  the  epithelium  and  blood-corpuscles,  are,  with  larger  or 
shorter  intervals,  sometimes  as  often  as  twice  a  week,  found  lying 
loose  in  the  vagina,  or  are  easily  detached  from  it  without  causing 
bleeding.  At  other  times  the  membranes  consist  of  coagulated  fibrin, 
including  blood-corpuscles  and  epithelial  cells. 


DISEASES  OF  THE   VAGINA.  349 

Astringents  make  the  condition  worse.  General  treatment,  espe- 
cially with  bromide  of  potassium  in  large  doses,  has  had  better  effect. 

Emphysematous  Vaginitis  (Colpohyperplasia  cystica — Winckel). — 
Although  not  very  common,  this  disease  is  frequent  enough  to  have 
been  observed  by  a  number  of  different  gynecologists,  and  some  have 
treated  several  cases  of  it.  A  prominent  gynecologist  of  this  city  has 
told  me  how  puzzled  he  felt  when  he  was  consulted  about  a  case  of  this 
kind,  as  he  had  not  the  slightest  idea  what  it  was.  It  is  characterized 
by  the  presence  in  the  upper  part  of  the  vagina  arid  on  the  vaginal 
portion  of  numerous  translucent,  pink,  gray,  or  blueish,  soft  cysts, 
varying  in  size  from  a  millet-seed  to  a  hazelnut.  They  are  situated 
superficially,  contain  a  serous  fluid,  and  often  gas.  Some  have  a 
central  depression.  Sometimes  they  give  a  crackling  sensation  like 
emphysema.  When  pricked,  the  gas  escapes  with  a  distinct  wheezing 
sound  and  the  cyst  collapses.  The  disease  is  most  common  in  preg- 
nancy, but  has  been  found  in  virgins,  but  always  in  women  suffering 
from  profuse  catharrhal  discharge.  It  does  not  give  rise  to  any  symp- 
toms, except  that  the  introduction  of  the  speculum  is  painful,  and  it 
disappears  within  two  weeks  after  childbirth. 

It  is  not  definitely  determined  where  the  gas  is  found,  whether  in  the 
interstitial  connective  tissue,  in  lymph -follicles,  or  lymphatic  vessels ; 
but  it  seems  most  likely  that  the  condition  is  caused  by  stasis  in  veins 
and  lymphatics,  extravasation  of  blood,  and  decomposition  of  the  same, 
with  formation  of  gas.  That  atmospheric  air  should  be  drawn  in  and 
prevented  from  escaping  by  closure  of  the  entrance  seems  hardly  pos- 
sible. 

Treatment. — In  pregnant  women  no  treatment  is  needed,  since  the 
disease  causes  no  discomfort  and  disappears  after  childbirth.  In  others 
it  has  been  recommended  to  pour  dilute  hydrochloric  acid  (1  per  cent.) 
through  a  Fergusson  speculum  on  the  affected  parts,  or  use  injections 
with  solutions  of  carbolic  acid  or  corrosive  sublimate. 

Mycotie  Vaginitis. — Two  kinds  of  fungi  may  grow  in  the  vagina — 
namely,  Leptothrix  vaginalis  and  O'idium  albicans.  Leptothrix  con- 
sists in  fine  threads  with  oval  spores.  Oi'ditim  has  hair-like  branches. 
It  is  probably  the  same  fungus  as  the  one  forming  thrush  in  the 
mouth. 

Symptoms. — Leptothrix  gives  rise  to  hardly  any  discomfort.  Oidium 
causes  sometimes  intense  pruritus,  a  burning  sensation,  swelling,  dis- 
charge, and  even  fever.  The  disease  may  end  in  a  few  days,  but 
may  also  last  several  weeks  or  months,  especially  in  pregnant  women. 
The  mucous  membrane  of  the  vagina  is  red,  tender,  and  studded  with 
small  white  spots,  which  can  only  be  removed  together  with  the  epi- 
thelium, and  under  the  microscope  prove  to  be  composed  of  liyphee 
and  spores. 

Etiology. — Vaginitis  and  pregnancy  predispose  to  the  development 


350  DISEASES  OF  WOMEN. 

of  fungi.  These  may  be  directly  brought  in  during  coition  with  men 
affected  with  diabetes,  a  disease  which  frequently  is  accompanied  by 
the  presence  of  fungi  between  the  prepuce  and  the  gland.  They  may 
also  be  carried  on  fingers  that  have  handled  flour — e.  g  those  of  mil- 
lers or  bakers. 

Prognosis. — The  prognosis  is  good,  and  the  disease  can  be  cured  in 
a  fortnight. 

Treatment. — Frequent  vaginal  injections  with  sulphate  of  copper 
(1-2  per  cent.),  salicylic  acid  (1-2  per  thousand),  carbolic  acid  (3  per 
cent.),  creolin  (1  per  cent.),  or  corrosive  sublimate  (1-2  per  thousand). 
The  last-named  substance  should  not  be  used  in  pregnant  women, 
on  account  of  the  danger  of  absorption  (p.  199).  The  same  solutions 
may  be  used  for  swabbing  the  vagina  through  a  speculum.  Warm 
sitz-baths,  with  addition  of  a  little  soda  or  borax,  or  injections  with 
flaxseed  tea  and  similar  emollient  substances,  are  particularly  indi- 
cated in  the  beginning,  if  the  inflammation  is  more  acute. 

B.  Exudative  Vaginitls. — A  fibrinous  exudation  takes  place  on 
the  surface  or  in  the  mucous  membrane  of  the  vagina.  It  makes  its 
first  appearance  as  discrete  spots  not  larger  than  millet-seeds,  but  soon 
these  spots  extend  in  all  directions  and  melt  together,  so  as  to  form 
one  or  more  large,  thick  patches.  The  parts  surrounding  the  patches 
are  more  or  less  swollen,  dark  red,  brown,  or  dirty  greenish.1 

It  is  not  settled  whether  this  condition  is  identical  with  the  process 
that  takes  place  in  the  throat  in  the  disease  called  diphtheria  or 
not. 

Etiology. — It  is  the  most  common  form  of  puerperal  infection.  It 
appears  also  in  severe  general  diseases,  such  as  typhus,  small-pox,  and 
measles.  Gonorrhea  rarely  gives  rise  to  it.  Local  irritants,  such  as 
too  strong  injections  of  bichloride  of  mercury,  may  cause  it.2 

Prognosis. — When  due  to  local  irritation  exudative  vaginitis  is  of 
slight  importance;  when  symptom  of  a  general  disease,  it  is  a  sign 
of  serious  systemic  disturbance;  and  when  caused  by  local  infection 
during  childbirth  or  in  the  puerperium,  there  is  imminent  danger  of 
general  infection,  which  may  end  in  death. 

Treatment. — If  the  condition  is  due  to  local  irritants,  they  must,  as 
far  as  possible,  be  removed  and  mild  healing  substances,  such  as  vase- 
line, glycerate  of  tannin,  a  weak  solution  of  borax,  used  for  applica- 
tion or  injection. 

If  it  appears  as  result  of  local  infection,  an  entirely  different  course 
should  be  followed.  In  my  experience  the  best  practice  is  to  use 
cauterization  with  chloride  of  zinc  dissolved  in  equal  parts  of  dis- 

1  For  further  details  see  Garrigues,  "  Puerperal  Diphtheria,"  Trans.  Afaer.  Gyn. 
Soc.,  1885,  vol.  x.  p.  96. 

*  Garrigues,  "  Corrosive  Sublimate  and  Creolin  in  Obstetric  Practice,"  Amer.  Jour. 
Med.  Sci.,  1889,  vol.  xcviii.  p.  115. 


DISEASES  OF  THE   VAGINA.  351 

tilled  water.  Others  use  pure  carbolic  acid,  Monsel's  solution  of  sub- 
sulphate  of  iron  mixed  with  glycerin,  tincture  of  iodine,  iodoform,  etc. 

When  it  is  a  part  of  a  general  systemic  infection,  the  preparations 
of  iodine  and  iron  may  be  used  locally  in  connection  with  general 
tonic  treatment. 

Dysenteric  Vaginitis. — This  is  a  variety  of  exudative  vaginitis, 
sometimes  found  in  patients  suffering  from  chronic  dysentery,  and 
who  have  a  gaping  vulva,  through  which  the  dysenteric  process 
extends  into  the  lower  part  of  the  vagina.  Small  gray  membranes, 
composed  of  loosened  epithelium,  and  superficial  ulcers  surrounded 
by  a  dark  area  with  overfilled  blood-vessels,  form  on  the  mucous 
membrane.  In  and  under  the  epithelium  are  found  layers  of  micro- 
cocci. 

Treatment. — Besides  treating  the  affection  of  the  intestine — espe- 
cially by  regulation  of  diet,  astringent  medicines,  injection  with  a 
teaspoonful  of  subnitrate  of  bismuth  in  a  cupful  of  boiled  starch,  or 
even  cauterization  with  nitric  acid — the  vagina  must  be  treated  as 
stated  above. 

C.  Phlegmonous  Vaginitis. — Phlegmonous  vaginitis  is  the  inflam- 
mation of  the  connective  tissue  surrounding  the  vagina. 

1.  One  form  of  this,  and  the  most  characteristic,  is  that  known  as 
dissecting  vaginitis,  in  which  the  whole  vagina,  with  the  vaginal  por- 
tion of  the  uterus,  is  loosened  by  suppuration  from  the  neighboring 
tissue  and  expelled  in  one  mass.  Only  a  few  cases  of  this  affection 
have  been  reported.  They  appeared  in  the  course  of  severe  feverish 
diseases,  such  as  typhoid  fever,  pneumonia,  perhaps  gonorrhea,  and 
the  affection  in  all  came  on  immediately  after  menstruation. 

Symptoms. — The  patient  complains  of  more  or  less  intense  pain. 
There  is  a  sanious  discharge.  The  labia  majora  are  swollen  and  the 
seat  of  superficial  ulceration.  The  mucous  membrane  of  the  vagina 
is  swollen,  pale,  or  necrotic.  After  the  expulsion  of  the  vagina  the 
surface  heals  by  granulation,  and  considerable  stenosis  is  liable  to 
follow. 

Treatment. — A  tampon  soaked  in  camphor  emulsion — 

R.  Camphorae,  3ss; 

Mucilag.  acacise,  3j ; 

Aquae,  3iv. 
M. — Sig.  Shake  well — 

should  be  kept  in  the  vagina  until  all  necrosed  tissue  is  separated. 
The  separation  should  be  aided  by  cautious  pulling  and  cutting  of 
resistant  sinewy  strings.  After  expulsion  the  surface  should  be  dusted 
with  iodoform  or  smeared  with  iodoform  ointment,  and  stenosis  should 
be  guarded  against  by  the  use  of  tampons  and  the  frequent  introduction 
of  a  speculum. 


352  DISEASES  OF  WOMEN. 

2.  Another  form  of  phlegmonous  vaginitis  is  caused  by  the  burrow- 
ing of  pus  from  a  pelvic  abscess.  For  a  time  a  fluctuating  swelling  is 
felt  somewhere  on  the  wall  of  the  vagina,  and  later  this  opens  into 
the  vagina  or  the  rectum.  Often  fistulous  tracts  remain  for  a  long 
time,  and  the  suppuration  may  finally  exhaust  the  patient's  strength 
and  lead  to  her  death. 

Treatment. — An  abscess  of  the  latter  kind  should  be  freely  opened 
from  the  vagina  as  soon  as  felt.  The  cavity  should  be  injected  with 
antiseptic  fluids  and  loosely  packed  with  iodoform  gauze.  Later  it 
may  be  necessary  to  dilate  fistulous  tracts  with  laminaria  or  the  knife. 

Vulvo-vaginitis  in  Children. — The  vagina  and  vulva  are  not  infre- 
quently inflamed  in  infants  and  children.  The  inflammation  may 
be  catarrhal  or  gonorrhea! .  The  catarrhal  form  is  produced  by 
uncleanliness,  foreign  bodies,  pinworms,  masturbation,  enuresis,  hyper- 
acid  urine,  or  eruptive  fevers.  The  gonorrheal  is  due  to  the  pres- 
ence of  the  gonococcus.  There  seems  also  to  be  an  infectious,  non- 
gonorrheal  form. 

The  treatment  should  consist  in  cleanliness,  antacids  given  inter- 
nally, and  injections  of  a  quart  of  1 : 3000  solution  of  permanganate 
of  potash,  made  with  a  soft-rubber  catheter  and  repeated  three  times 
a  day.  This  leads  to  a  cure  in  from  twelve  to  fifteen  days. 


CHAPTER  VIII. 

GANGRENE  OF  THE  VAGINA. 

Etiology. — Gangrene  of  the  vagina  may  be  caused  by  the  presence 
of  foreign  bodies — e.  g.  pessaries,  or  the  contact  with  caustics — e.  g. 
a  tampon  soaked  in  undiluted  liquor  ferri  chloridi  (p.  179).  It  may 
be  due  to  pressure  of  the  head  of  the  child  where,  in  consequence  of 
mechanical  disproportion  between  the  child  and  the  pelvic  canal,  im- 
paction  is  allowed  to  take  place.  The  most  common  locality  of  this 
occurrence  is  the  upper  part  of  the  anterior  wall  of  the  vagina,  which 
is  caught  between  the  head  of  the  child  and  the  symphysis  pubis,  and 
leads  after  the  separation  of  the  necrosed  plug  to  the  formation  of  a 
vesico-vaginal  fistula. 

Gangrene  of  the  vagina,  like  that  of  the  vulva,  may  appear  in 
conjunction  with  noma,  and  is  then  perhaps  due  to  direct  transmission 
of  toxic  material  from  the  cheek  to  the  genitals.  It  may  also  be 
brought  about  by  diptheritic ^vaginitis  (p.  350). 

Morbid  Anatomy. — The  whole  mucous  membrane,  inclusive  of  that 


DISEASES  OF  THE   VAGINA.  353 

covering  the  vaginal  portion  of  the  uterus,  may  be  changed  to  a  black, 
pulpy  malodorous  mass,  and  the  destruction  may  extend  more  or  less 
into  the  depth  of  the  underlying  tissue. 

Symptoms. — Gangrene  is  accompanied  by  pain,  dysuria,  inability  to 
walk,  and  sometimes  hemorrhage,  which  may  even  become  fatal. 
Fever  is  not  always  present. 

Treatment. — The  vagina  should  be  injected  with  solutions  of  car- 
bolic acid,  creolin,  or  acetate  of  alumina  (1  per  cent.),  and  a  tampon 
with  the  above-mentioned  camphor  emulsion  (p.  351)  or  a  saturated 
solution  of  chlorate  of  potash  left  in  it.  Dead  tissue  should  be 
removed  as  soon  as  feasible.  The  granulating  surface  should  be 
dusted  with  iodoform  or  smeared  with  iodoform  ointment,  and  care 
taken  to  obviate  stenosis  (pp.  330,  331).  The  general  treatment  con- 
sists in  a  liberal  use  of  stimulants,  tonics,  and  a  nourishing  diet. 


CHAPTER   IX. 

ERYSIPELAS  OF  THE  VAGINA. 

IN  a  patient  who  died  of  general  erysipelas  the  affection  had  spread 
to  the  vagina.  The  entire  mucous  membrane  was  red,  swollen,  wrin- 
kled, and  studded  with  vesicles,  and  in  some  places  the  epithelium 
had  been  thrown  off. 

Treatment. — If  the  erysipelatous  inflammation  is  discovered  in 
time,  the  vagina  should  be  cleaned 'with  creolin  injections  and  dusted 
with  iodoform  in  conjunction  with  the  general  treatment  of  erysipelas. 


CHAPTER   X. 

CICATRICES. 

THE  vagina  is  often  the  seat  of  cicatricial  tissue,  resulting  from 
inflammation,  ulceration,  or  gangrene.1 

Etiology. — The  most  common  cause  is  a  laceration  and  sloughing 
occurring  in  childbirth.  Cicatrices  may  also  be  formed  by  the  use 
of  caustics — e.  g.  chloride  of  zinc  for  diphtheritic  ulcers  (p.  350). 
Unsuccessful  plastic  operations,  where  large  surfaces  heal  by  granula- 
tions, leave  also  large  scars. 

Symptoms. — The  presence  of  such  cicatricial  tissue  may  give  rise  to 

1  A  valuable  paper  on  this  subject  by  Skene,  with  important  remarks  by  T.  A. 
Emmet,  is  found  in  Tram.  Amer.  Gyn.,  1876,  vol.  i.  p.  91,  et  seq. 
23 


354  DISEASES  OF  WOMEN. 

pain,  which,  although  the  lesion  is  permanent,  may  be  intermittent  or 
remittent.  This  pain  is  probably  due  to  irritation  of  fine  nervous 
fibrillaB  enclosed  in  the  scar.  By  reflex  action  neighboring  organs 
often  become  painful,  so  that  the  patient  suffers  from  dysuria  and 
dyschezia ;  but  reflex  neuroses  may  also  appear  in  remote  parts  of  the 
body — e.  g.  in  the  pit  of  the  stomach,  under  the  left  breast,  etc. 
Cicatricial  bands  extending  between  the  walls  of  the  vagina  or  be- 
tween them  and  the  vaginal  portion  of  the  uterus,  or  ring-shaped 
contraction  of  the  vagina,  may  cause  dyspareunia,  and,  when  the 
constriction  is  considerable,  even  dysmenorrhea.  The  condition  may 
end  in  complete  atresia  with  all  its  consequences. 

The  cicatricial  band  may  frustrate  the  use  of  vaginal  pessaries,  and 
place  serious  obstacles  in  the  way  of  success  in  operating  for  vaginal 
fistulae. 

The  scar  tissue  is  harder,  less  elastic,  of  lighter  color  than  the 
normal  vaginal  wall,  and  has  a  smooth  surface.  During  pregnancy 
it  softens  very  much,  so  that  even  extensive  scars  need  not  give 
trouble  in  a  subsequent  childbirth. 

Treatment. — As  prophylaxis  care  should  be  taken,  in  employing 
caustics,  not  to  use  them  on  larger  surfaces  nor  to  a  greater  depth  than 
is  absolutely  necessary.  To  prevent  the  formation  of  these  cicatricial 
bands  after  childbirth  by  the  use  of  sutures  is  hardly  feasible,  since 
they  are  formed  on  bruised  and  sloughing  tissues  which  could  not  be 
united  in  that  way.  Sometimes  a  judicious  use  of  tampons  or  dila- 
tors during  the  healing  of  a  suppurating  surface  may,  however,  limit 
the  evil  considerably. 

The  curative  treatment  has  recourse  to  three  methods — incision, 
excision,  and  insertion  of  flaps  of  healthy  tissue.  A  projecting  thin 
band  may  simply  be  severed. 

If  the  cicatrice  is  imbedded  in  the  tissue  like  a  cord  and  is  not  too 
extensive,  it  may  be  cut  out,  and  the  edges  united  with  sutures.  If 
it  is  very  long,  it  is  divided  into  sections ;  the  edges  of  which  are 
separated  half  an  inch  or  more  if  possible,  and  healthy  tissue  brought 
in  between  from  each  side  to  fill  the  gap,  where  it  is  secured  by  inter- 
rupted sutures. 

If  the  cicatricial  surface  is  spread  out  and  superficial,  it  is  to  be 
snipped  through  with  the  points  of  a  pair  of  scissors  at  regular  inter- 
vals. Another  parallel  column  of  incisions  is  formed  in  the  same 
manner,  but  in  such  a  way  that  the  cuts  are  placed  opposite  the 
spaces  between  two  and  two  incisions  in  the  first  column.  Thus  the 
whole  surface  is  gone  over  and  kept  on  the  stretch  during  the  heal- 
ing process  by  means  of  a  glass  plug  (p.  330),  or  better ,  by  Boze- 
man's  vaginal  dilators,  consisting  of  cylinders  of  hard  rubber  with 
rounded  ends  and  attachment  for  a  string.  Others  recommend  slip- 
pery-elm bark  made  into  a  roll  and  beaten  till  it  is  soft.  Before 


DISEASES  OF  THE   VAGINA.  355 

introduction  it  is  dipped  in  carbolized  water  (1  per  cent.).     It  swells 
slowly  and  promotes  healing. 


CHAPTER    XL 
VAGINISMUS. 

VAGINISMUS  consists  in  a  painful  tetanic  contraction  of  one  or 
more  muscles  surrounding  the  vagina. 

According  to  its  seat  it  may  be  divided  into  two  species — superficial 
and  deep  vaginismus.  The  superficial  has  its  seat  at  the  entrance  of 
the  vagina  (see  p.  43),  probably  in  the  bulbo-cavernosus  muscle. 
The  deep  is  a  spasm  of  the  levator  ani  muscle.  The  superficial  is 
commonly  found  in  women  with  an  intact  hymen,  the  disease  itself 
preventing  sexual  connection,  but  may  be  developed  in  women  who 
have  even  borne  children. 

Etiology. — Nearly  always  some  palpable  local  disease  is  found  in 
the  genitals  or  the  neighboring  organs,  such  as  an  inflamed  hymen, 
irritable  carunculee  myrtiformes,  fissures  of  the  fourchette  or  vaginal 
entrance,  a  neuroma  of  the  fossa  navicularis,  a  urethral  caruncle,  a 
fissure  of  the  neck  of  the  bladder  or  of  the  anus,  vulvitis,  vaginitis, 
a  granular  os  uteri,  eudometritis,  displacement  of  the  uterus,  or  pelvic 
inflammation.  An  unusually  large  male  member  or  awkwardness  in 
its  use  may  bring  about  some  of  the  above-named  conditions,  and  thus 
be  the  cause  of  the  disease,  but  more  frequently  the  underlying  fault 
is  a  nervous  disposition  and  fear  of  pain  in  the  female.  Lead-poison- 
ing is  also  said  to  produce  vaginismus. 

Symptoms. — In  superficial  vaginismus  it  is  not  only  the  attempt  at 
coition  that  brings  on  a  spasm  of  the  muscles  surrounding  the  vagi- 
nal entrance,  which  closes  it  against  the  introduction  of  the  penis,  but 
the  spasm  is  observed  when  the  physician  tries  to  make  a  digital 
examination  or  introduce  a  speculum  ;  even  the  slightest  touch  witli  a 
feather  or  a  camel's-hair  brush  or  the  introduction  of  a  catheter  into 
the  urethra  may  suffice  to  bring  about  the  tetanic  contraction.  Some- 
times the  sphincter  aui  muscle  may  enter  into  a  similar  condition,  or 
even  general  convulsions  of  the  whole  body  be  added.  I  have  seen 
opisthotonus  arise  which  would  have  sufficed  to  throw  any  man  aside. 

Deep  vaginismus  also  called  penis  captivus,  is  a  much  rarer  affection, 
consisting  of  a  similar  spasm  in  the  depth  of  the  vagina.  It  occurs 
during  coition  or  during  a  digital  examination.  No  difficulty  is  expe- 
rienced at  the  vaginal  entrance,  but  in  the  depth  of  the  tube  a  resist- 
ance is  met  with  in  the  shape  of  a  tetanically  contracted  circular  band, 
which  prevents  further  progress.  If  the  spasm  occurs  after  full  intro- 


356  DISEASES  OF  WOMEN. 

duction  of  the  penis,  the  corona  is  encircled,  and  the  attempts  to 
withdraw  the  penis  cause  great  pain  to  both  participants  in  the 
act. 

Prognosis. — If  neglected,  vaginismus  is  a  source  of  great  physical 
and  mental  misery;  if  properly  treated  a  cure  may  always  be  effected. 

Treatment. — If  one  of  the  above-named  causes  is  found,  it  must 
first  of  all  be  removed.  Fissures  of  the  hymen,  vaginal  entrance,  or 
anus  are  best  treated  with  pledgets  soaked  in  a  4  per  cent,  solution  of 
chloral  hydrate.  Others  recommend  ointments  with  opium,  bella- 
donna, or  other  narcotics.  Neuromata,  urethral  caruncles,  and  car- 
unculse  myrtiformes  are  snipped  off  with  curved  scissors.  A  fissure 
of  the  neck  of  the  bladder  is  treated  with  overdistension,  cocaine 
bougies  left  to  melt  in  the  urethra — 

Jfy.  Cocaina?  hydrochlorat,          gr.  xij  ; 

Ol.  theobroraatis,  q.  s. 

M.  Ft.  bacilli,  No.  xii, 
Sig.  One  morning  and  evening — 

and  application  of  a  strong  solution  of  nitrate  of  silver.  In  regard 
to  the  other  affections  named,  the  reader  is  referred  to  the  chapters 
in  which  they  are  discussed. 

Much  benefit  may  be  derived  from  the  use  of  warm  hip-baths,  sup- 
positories with  iodoform  (gr.  v),  atropine  ointment  (gr.  ij  to  §j),  and 
the  application  twice  a  week  of  a  solution  of  nitrate  of  silver  (gr.  x 
or  xx  to  3j)  to  the  vulva  and  hymen,  followed  by  cold,  and  later 
lukewarm,  applications. 

The  galvanic  current,  with  the  soothing  positive  pole  on  the  affected 
parts,  has  given  good  results.. 

The  general  treatment  is  of  the  very  greatest  importance,  and  its 
aim  must  be  to  brace  the  patient  up  physically  and  morally.  If  feas- 
ible, she  should  be  separated  for  a  time  from  her  husband,  and,  at  all 
events,  all  attempts  at  sexual  intercourse  must  be  strictly  forbidden. 
She  should  have  pleasant  surroundings,  cheerful  company,  and  much 
exercise  in  the  open  air,  preferably  on  horseback.  She  should  take  a 
regular  course  of  gymnastics  tending  toward  muscular  development 
of  other  parts  and  control  over  the  nerves.  Hydrotherapy  is  also  very 
useful  in  drawing  away  the  abnormally  concentrated  sensibility  from 
the  genitals. 

If  these  two  lines  of  treatment,  removal  of  the  cause  and  general 
tonic  treatment,  do  not  lead  to  a  cure,  sharper  local  treatment  is  re- 
quired. The  patient  is  anesthetized  and  the  vaginal  entrance  forcibly 
distended  with  two  fingers  or  a  plurivalve  speculum.  As  after-treat- 
ment a  vaginal  glass  plug  (p.  330)  is  used  morning  and  evening  for 
a  couple  of  hours. 

Sometimes  the  removal  of  a  fleshy,  resistant,  hyperesthetic  hymen 
by  means  of  a  pair  of  curved  scissors  will  promptly  lead  to  a  com- 


DISEASES  OF  THE   VAGINA.  357 

plete  recovery.  In  other  cases  it  is  neceasary  to  follow  this  operation 
up  with  incision  of  the  vaginal  entrance. 

The  simplest  way  of  doing  this  is  to  insert  a  Sims  speculum  under 
•the  pubic  arch,  put  a  finger  into  the  rectum,  press  the  sphincter  ani 
up  against  the  posterior  vaginal  wall,  and  divide  with  scissors  on 
each  side  of  the  median  line  the  fibers  encircling  the  vaginal  entrance, 
leaving  a  space  of  three-quarters  of  an  inch  between  the  two  incisions 
(T.  A.  Emmet). 

Another  mode  of  incision  is  to  imitate  the  tear  in  the  median  line 
through  the  perineal  body  that  often  takes  place  in  childbirth  (T.  G. 
Thomas). 

Sims's  operation  is  a  very  bloody  one,  and  may  with  advantage  be 
replaced  by  one  of  the  two  already  mentioned.  After  excision  of  the 
hymen  the  left  index  and  middle  fingers  are  introduced  into  the 
vagina  and  spread  out,  so  as  to  dilate  the  vagina  as  much  as  possible 
and  put  the  posterior  commissure  on  the  stretch.  Next  a  deep  incis- 
ion is  made  with  a  scalpel  through  the  vaginal  tissue  on  one  side  of 
the  median  line,  downward  and  inward,  ending  in  the  raphe  of  the 
perineum.  This  incision  forms  one  branch  of  a  Y.  Then  the  knife  is 
reintroduced  into  the  vagina,  which  is  yet  kept  dilated  by  the  fingers, 
and  a  similar  incision  is  made  on  the  other  side  from  above  downward 
and  inward.  These  two  incisions  are  united  in  or  near  the  raphe, 
and  prolonged  as  a  single  incision  to  the  integument  of  the  perineum. 
Each  of  these  incisions  will  be  about  two  inches  long — namely,  half 
an  inch  above  the  edge  of  the  bulbo-cavernosus  muscle,  half  an  inch 
across  its  fibers,  and  an  inch  from  its  lower  edge  to  the  skin  of  the 
perineum.  The  glass  plug  is  introduced  immediately,  and  effective 
compression  exercised  by  means  of  compresses  and  a  T-bandage. 

Neurotomy  of  the  pudic  nerve  in  the  perineum  has  been  advised, 
but  reference  to  the  anatomical  description  (p.  109),  will  show  that 
not  even  its  main  branch,  the  perineal  nerve,  is  within  reach.  The 
branches  of  the  latter  may  indeed  be  cut  by  deep  lateral  incisions,  but 
the  danger  of  a  hemorrhage  hard  to  control  is  very  great,  and  simply 
severed  nerves  grow  easily  together. 

The  deep  vaginismus  is  treated  by  attention  to  the  cause,  especially 
a  granular  os,  by  the  same  general  treatment  as  recommended  for 
the  superficial  form,  and  to  overcome  the  spasm  that  keeps  the  penis 
captive  the  introduction  of  a  finger  into  the  rectum  has  been  recom- 
mended. All  attempts  at  violent  separation  must  be  desisted  from. 
The  captive  has  to  remain  imprisoned  until  the  subsidence  of  the 
spasm  or  erection  allows  an  easy  withdrawal.  If  ether  is  available, 
the  mere  administration  of  it  would  probably  end  the  spasm,  even 
before  anesthesia  is  produced. 


358  DISEASES  OF   WOMEN. 

CHAPTER   XII. 
NEOPLASMS. 

1.  Cysts.1 — Cysts  are  rather  frequently  found  in  the  vagina.  As 
a  rule,  the  patients  are  adults,  but  congenital  cysts  have  been  seen  in 
the  vagina  of  new-born  children.  Commonly  these  cysts  are  single, 
but  occasionally  two  or  more  are  found  in  the  same  individual.  They 
are  most  frequently  situated  on  the  anterior  wall.  They  are  globular 
or  oblong,  mostly  sessile,  but  may  become  pedunculated  and  hang  out 
from  the  vulva.  They  grow  very  slowly,  and  have  often  been 
observed  for  many  years.  They  vary  in  size  from  that  of  a  pigeon's 
egg  to  that  of  a  goose  egg,  but  may  exceptionally  reach  the  size  of 
the  fetal  head  at  term. 

The  wall  varies  in  thickness  from  half  a  millimeter  (^  inch)  to 
a  centimeter  (|-  inch).  It  is  composed  of  connective  tissue,  and  some- 
times muscle-fibers.  The  inside  may  be  lined  with  simple  or  ciliated 
columnar  or  with  flat  epithelium,  or  be  without  epithelium. 

The  contents  may  also  vary  very  much.  They  may  be  serous,  yel- 
lowish, purulent,  or  thick  and  chocolate-colored.  Sometimes  they  do 
not  contain  form-elements ;  in  other  cases  we  find  blood-corpuscles, 
pus-corpuscles,  oil-globules,  granular  cells,  epithelial  cells,  or  choles- 
terin  crystals. 

As  a  rule,  the  mucous  membrane  covering  the  cyst  is  freely  mov- 
able and  normal,  but  sometimes  it  becomes  atrophic.  The  cysts  may 
burst  spontaneously  with  or  without  suppuration,  or  be  ruptured  by 
injury,  especially  childbirth.  The  contents  may  be  discharged  into 
the  vagina,  the  bladder,  the  urethra,  or  through  the  perineum. 

Vaginal  cysts  may  have  very  different  origins.  They  may  be 
formed  by  condensation  of  the  perivaginal  connective  tissue  round 
an  extravasation  of  blood.  They  may  be  retention  cysts,  due  to 
closure  of  the  outlet  of  the  glands  of  the  mucous  membrane  which 
some  observers  have  found  (p.  44).  Some  have  been  explained  as 
dilated  lymphatics.  Another  theory  is  that  some  are  developments 
of  part  of  one  of  the  Miillerian  ducts  which  has  failed  to  unite  with 
its  fellow  in  the  formation  of  the  vagina.  Some  are  most  likely 
formed  in  Gartner's  canal,  and  may  then  communicate  with  a  par- 
ovarian  cyst.2  Perhaps  some  are  developed  from  periurethral  glands. 

Symptoms. — If  these  cysts  are  small  they  may  not  give  rise  to  any 
symptoms,  and  are  discovered  accidentally  during  delivery  or  gyne- 

1  An  exhaustive  paper  on  the  subject  hy  Dr.  G.  W.  Johnston  of  Washington,  D. 
C.,  can  be  found  in  Amer.  Journ.  Obst.,  1887,  vol.  xx.  p.  1121. 

2  Garrigues's  report  on  a  cyst  extirpated  by  Dr.  K.  Watts,  Amer.  Jour.  Obst.,  1881, 
p.  849,  and  a  note  on  Gartner's  canals  in  New  York  Med.  Jour.,  March  31,  1883,  vol. 
xxxvii.  p.  348. 


DISEASES  OF  THE   VAGINA.  359 

cological  examination  instituted  for  other  purposes.  If  they  are  of 
considerable  size,  they  cause  dyspareunia  and  a  bearing-down  sensation. 
They  may  also  cause  leucorrhea,  dysuria,  and  dyschezia.  Sometimes 
they  are  fluctuating. 

Prognosis. — Many  of  them  give  no  trouble;  they  grow  slowly  or 
become  stationary ;  if  necessary  they  can  easily  be  removed. 

Diagnosis. —  Cystocele  may  resemble  a  cyst  very  much,  but  the 
swelling  disappears  when  a  catheter  is  introduced  into  the  bladder. 
In  emphysematous  vaginitis  there  is  a  large  number  of  small  cysts  in  the 
fornix,  and  on  being  punctured  they  are  found  to  contain  gas.  Cysts 
of  the  vagina  are  single  or  few  in  number,  of  larger  size  and  filled 
with  a  fluid.  From  solid  growths  they  differ  by  their  fluctuation  or 
elasticity,  or  by  yielding  fluid  when  exploratory  puncture  is  resorted 
to.  Hydatids  of  the  pelvis  are  filled  with  a  clear,  colorless  fluid  without 
albumin,  containing  the  characteristic  booklets,  or  perhaps  a  piece  of 
cuticula  with  its  pathognomonic  parallel  structureless  lay  ere. 

Treatment. — The  best  way  is  to  extirpate  them  and  unite  the  edges 
by  suture.  In  order  to  facilitate  the  extirpation  if  the  wall  is  thin, 
they  may  be  emptied  and  injected  with  melted  spermaceti,  which  is 
thereafter  solidified  by  the  application  of  ice.1  But  their  relation  to 
the  bladder  may  be  so  intimate  that  we  would  risk  cutting  into  that 
viscus.  Under  such  circumstances  partial  excision  of  the  wall  is 
preferable.  The  most  prominent  point  is  seized  with  tenaculum-for- 
ceps  or  volsella  and  the  anterior  wall  of  the  cyst  cut  off  with  the 
covering  mucous  membrane  of  the  vagina,  leaving  the  bottom  of  the 
cyst  undisturbed.  In  order  to  arrest  hemorrhage  and  avoid  sup- 
puration the  edges  of  the  mucous  membrane  may  be  sutured  to  those 
of  the  cyst  (Schroeder's  method),  the  wall  of  which  changes  character 
and  becomes  like  the  rest  of  the  vagina.  It  may  also  simply  be  left, 
and  is  later  exfoliated.  During  this  process  antiseptic  injections  should 
be  used. 

When  the  vaginal  cyst  communicates  with  a  parovarian  cyst,  it  is 
recommended  to  open  the  vaginal  cyst  as  far  as  the  base  of  the  broad 
ligament  with  the  therm o-cautery,  and  treat  the  parovarium  with 
iodized  injections  and  a  drainage-tube.2 

2.  Fibroids  (Fibroma,  Myofibroma,  Fibromyoma). — Fibrous  tumors 
of  the  vagina  are  rather  rare,  especially  when  compared  with  their 
frequency  in  the  uterus.  Their  most  common  seat  is  the  upper  part 
of  the  anterior  wall.  They  are  very  rarely  pure  fibroids ;  that  is  to 
say,  composed  of  connective  tissue  alone.  As  a  rule,  this  tissue  is 
intermixed  with  a  greater  or  lesser  amount  of  unstriped  muscular 
fibers.  Their  starting-point  may  be  in  the  submucous  or  perivaginal 
connective  tissue  or  in  the  muscular  coat  of  the  vagina.  Sometimes 

1  Pozzi's  method.     (Compare  p.  290.) 

2  Amand  Routh,  Trans.  Obst.  Soc.  London,  vol.  xxxvi. 


360  DISEASES  OF  WOMEN. 

a  fibroid  in  the  recto-vaginal  partition  is  in  reality  a  uterine  fibroid 
that  has  developed  downward,  just  as,  on  the  other  hand,  a  true  vagi- 
nal fibroid  may  extend  into  the  vulva. 

According  to  the  predominance  of  the  connective  or  muscular  ele- 
ment, these  tumors  are  harder  or  softer.  Like  similar  tumors  of  the 
uterus,  they  may  undergo  a  softening  by  accumulation  of  serous  fluid 
in  the  mesh  work  of  their  interior. 

Originally  they  are  globular  sessile  tumors  imbedded  in  the  wall  of 
the  vagina,  but  when  their  weight  increases  they  have  a  tendency  to 
become  pedunculated,  and  may  then  even  protrude  through  the  vulva. 
Such  pedunculated  tumors  are  called  fibroid  vaginal  polypi.  Exposed 
to  the  air  and  friction  of  the  clothes,  they  may  begin  to  ulcerate  on 
the  exposed  surface.  In  the  lower  part  of  the  vagina  they  often 
become  intimately  adherent  to  the  urethra. 

As  a  rule,  they  are  single. 

Etiology. — They  may  be  small  as  a  pea,  but  they  may  also  become 
quite  large  and  weigh  up  to  ten  pounds.  Their  growth  is  a  very  slow 
one,  and  may  extend  over  many  years.  They  are  commonly  found 
in  adults,  but  may  occur  in  children.  The  cause  that  produces  them 
is  unknown. 

Symptoms. — When  small  they  give  rise  to  no  symptoms,  and  are 
found  accidentally.  When  they  increase  in  size  they  cause  leucorrhea. 
When  they  become  still  larger  and  heavier,  they  cause  a  dragging  sen- 
sation, dyspareunia,  dysuria,  dyschezia,  and  may  oppose  a  very  serious 
obstacle  to  childbirth.  Sometimes  they  are  accompanied  by  severe 
hemorrhage. 

Diagnosis. — When  small  or  middle-sized,  they  are  easy  to  diagnos- 
ticate by  their  elastic  hardness.  It  is  true,  a  thick -walled  cyst  gives  a 
somewhat  similar  sensation,  but  all  doubt  may  be  dispelled  by  means 
of  an  aspirator.  When  they  are  large  enough  to  fill  the  vagina,  it 
may  be  difficult  to  differentiate  them  from  uterine  fibroid  polypi.  If 
it  is  possible  to  reach  the  os,  this  will  be  found  undilated,  and  no  ped- 
icle passes  out  through  it.  From  sarcoma  a  fibroid  is  distinguished 
by  its  slow  growth  ;  it  does  not  undermine  the  constitution ;  and  the 
microscopical  structure  is  entirely  different. 

Prognosis. — The  prognosis  is  favorable.  Small  fibroids  give  no 
trouble.  They  grow  slowly,  and  if  necessary  they  can  be  removed 
by  operation.  When  they  suppurate,  there  is,  however,  danger  of 
septicemia. 

Treatment. — A  pedunculated  fibroid  may  be  removed  by  tying  an 
elastic  ligature  around  the  pedicle,  which  will  be  severed  in  a  few 
days.  Or  it  may  be  cut  at  once  with  an  ecraseur  or  a  gal vano- caustic 
snare,  or  transfixed  with  a  needle  armed  with  a  strong  double  silk 
ligature,  which  is  cut  in  the  middle,  and  the  two  halves  crossed  and 
tied  on  either  side,  when  they  are  interlocked  like  the  links  of  a  chain. 


DISEASES  OF  THE   VAGINA.  361 

Finally  the  tumor  is  cut  off.     Any  of  these  methods  prevents  hemor- 
rhage. 

A  sessile  fibroid  is  removed  by  making  an  incision  over  its  longest 
diameter  and  enucleating  it.  In  order  to  avoid  hemorrhage,  fingers 
and  blunt  instruments  should  be  used  as  much  as  possible.  The 
galvano-caustic  knife  or  the  thermo-cautery  may  occasionally  be  used 
to  advantage  when  there  is  much  hemorrhage.  If  the  tumor  is  large, 
a  part  of  the  mucous  membrane  covering  it  is  included  between  two 
curved  incisions  blending  at  their  ends,  and  the  circumscribed  piece  is 
left  on  the  tumor.  After  plain  enucleation  the  edges  of  the  wound 
are  brought  together  with  deep  sutures.  Otherwise  the  wound  must 
be  packed  with  iodoform  gauze. 

3.  Mucous  Polypi. — Rarer  than  the  hard  fibroid  polypi  are  soft 
growths  of  similar  shape,  in  structure  like  the  mucous,  or  glandular, 
polypi  so  common  in  the  cervical  canal.     They  give  rise  to  the  same 
symptoms  as  fibroid  polypi.     They  are  very  vascular,  and  the  safest 
way  to  remove  them  is,  therefore,  by  means  of  the  elastic  ligature  or 
by  transfixion  of  the  pedicle,  as  just  described. 

4.  Sarcoma. — This  is  a  rare  disease.     It  appears  in  t\vo  forms — 
one  circumscribed,  forming  interstitial  globular  tumors  like  fibroids; 
the  other  diffuse,  extending  along  the  surface  like  carcinoma. 

It  has  been  noticed  that  of  the  small  number  of  cases  recorded 
comparatively  many  have  occurred  in  early  childhood. 

In  the  circumscribed  form  the  development  is  slower,  and  may 
take  a  couple  of  years,  but,  as  a  rule,  the  malignancy  of  the  tumor 
reveals  itself  by  its  rapid  growth. 

The  prognosis  as  to  a  complete  cure  is  very  doubtful,  as  this  affec- 
tion has  great  tendency  to  relapse  even  after  complete  extirpation. 

Symptoms. — In  adults  they  are  insignificant  in  the  beginning. 
Later  there  are  leucorrhea,  hemorrhage,  dysuria,  and  sensation  of 
pressure.  The  tumor  ulcerates  and  discharges  a  sanious  fluid.  The 
neighboring  organs  become  implicated,  and  the  general  health  is 
undermined.  In  children  the  symptoms  referable  to  pressure  on  the 
organs  in  the  pelvis  soon  become  pronounced. 

.Diagnosis. — The  diagnosis  from  fibroid  and  carcinoma  can  only  be 
made  by  microscopical  examination. 

Treatment.  —  Circumscribed  tumors  are  extirpated  like  sessile 
fibroids.  The  diffuse  form  may  be  kept  in  check  for  a  time  by 
curetting  and  cauterization  with  thermo-  or  galvano-cautery,  or  chlo- 
ride of  zinc  as  in  cancer  of  the  uterus. 

5.  Carcinoma. — Primary  carcinoma  of  the  vagina  is  a  rare  disease. 
As  a  rule,  it  is  secondary,  either  propagated   by  continuity  from 
neighboring  organs,   especially   the   cervix   uteri,   or   appearing  as 
metastatic  deposits  from  carcinoma  in  remote  parts. 

It  is  found  in  two  forms,  either  as  a  circumscribed  papillary  growth, 


362  DISEASES  OF  WOMEN. 

and  then  it  is  epitheliomatous  in  structure,  or  as  a  diffuse  carcinoma- 
tous  infiltration,  which  again  may  have  the  medullary  or  scirrhous 
type.  The  diffuse  form  affects  sometimes  the  shape  of  a  ring. 

The  cause  is  unknown.  The  disease  is  rarely  found  before  the  age 
of  thirty  years. 

Cancerous  tumors  develop  rapidly.  The  center  ulcerates  while  the 
periphery  spreads  over  the  neighboring  tissues.  In  consequence  of 
the  central  breaking  down,  fistulous  communications  with  other  canals 
may  be  formed,  the  most  frequent  of  which  is  a  recto-vaginal  fistula. 
The  lymphatic  glands  in  the  pelvis  and  at  the  groin  soon  swell. 

The  chief  symptoms  are  the  sanious,  dirty,  ill-smelling  discharge 
from  the  ulcer,  hemorrhage  and  pain,  to  which  may  come  the  common 
symptoms  due  to  pressure  and  obstruction,  dyspareunia,  dysuria,  dys- 
chezia,  and  dystocia. 

Diagnosis. — The  broad  basis,  the  friable  substance,  and  the  hem- 
orrhage caused  by  touch  are  characteristic.  The  friability,  the  ulcera- 
tion,  and  the  hemorrhage  serve  to  distinguish  the  papillary  epithelioma 
from  simple  papillomatous  vegetations  (p.  277).  From  sarcoma  car- 
cinoma can  only  be  distinguished  by  means  of  a  microscopical  exam- 
ination. The  distinction  between  primary  and  secondary  carcinoma 
is  of  great  importance  in  regard  to  treatment.  Bearing  in  mind  that 
the  vagina  is  rarely  the  original  seat  of  carcinoma,  we  must  carefully 
examine  all  neighboring  organs  from  which  it  may  have  spread,  and 
even  other  organs  from  which  germs  may  have  been  detached  and 
carried  to  the  vagina. 

Prognosis. — The  disease,  as  a  rule,  has  made  so  much  headway 
before  it  comes  under  treatment  that  a  radical  cure  is  impossible. 
Even  after  seemingly  complete  extirpation  relapse  is  common.  The 
whole  body  is  gradually  infected,  and  the  disease  soon  ends  in  death. 

Treatment. — If  there  is  any  possibility  of  operating  in  healthy  tis- 
sue, the  whole  tumor  should  be  extirpated  and  the  wound  closed  by 
sutures,  which  both  will  arrest  hemorrhage  and  bring  about  union  by 
first  intention.  In  this  respect  it  is  advised  not  even  to  abstain  from 
excising  parts  of  the  bladder  and  the  rectum,  the  edges  having  good 
tendency  to  unite  if  properly  brought  together  by  sutures.  Of  late 
it  has  even  been  demanded  that  under  all  circumstances  the  uterus 
should  be  removed.1 

In  most  cases  only  a  palliative  treatment  can  be  attempted,  but  life 
may  be  prolonged  and  sufferings  alleviated  by  a  judicious  use  of  the 
sharp  curette,  thermo-  or  galvano-cautery,  chloride  of  zinc,  or  bro- 
mine, applications  or  injections  of  chloride  of  iron,  creolin  injections, 
tonics  and  narcotics,  in  which  respect  the  reader  is  referred  to  the 
chapter  on  Carcinoma  of  the  Uterus. 

6.  Tuberculosis. — Tuberculosis  of  the  vagina  is  much  more  common 
1  Mackenrodt,  Oentralbl.f.  Gynak.,  1896,  vol.  xr.  No.  5,  p.  129. 


DISEASES  OF  THE   VAGINA.  363 

than  that  of  the  vulva,  but  is  still  rather  rare.  It  forms  ulcers  on 
the  posterior  wall  of  the  vagina,  owing  to  stagnation  of  infecting 
material  from  the  uterus,  the  disease  in  the  vast  majority  of  cases 
being  only  found  in  connection  with  tuberculosis  of  that  organ. 
Miliary  nodules,  ulcers,  and  caseous  masses  are  visible  in  the  vagina 
and  on  the  vaginal  portion  of  the  uterus,  and  the  microscopical  exam- 
ination shows  the  presence  of  bacillus  tuberculosis.  Tuberculous 
ulcers  form  easily  fistulas  opening  into  the  bladder,  the  urethra,  or 
the  rectum.  The  tuberculous  nature  of  these  fistulas  is  revealed  by 
the  presence  of  nodules  and  bacilli  around  their  opening. 

Such  fistulas  must  be  cut  out  in  a  wide  circumference.  Operations 
for  their  closure  oifer  scant  hope  of  success.  For  further  information 
the  reader  is  referred  to  what  has  been  said  about  the  same  affection 
in  the  vulva  (p.  288). 


CHAPTER    XIII. 

FlSTUL^E. 

Definition. — A  fistula  is  an  abnormal  opening  leading  from  the 
genital  canal  to  the  urinary  tract  or  the  intestines. 

In  a  more  limited  sense  the  word  is  only  applied  to  such  openings 
the  edge  of  which  is  covered  with  epithelium,  leaving  out  fresh 
wounds  extending  from  one  canal  to  the  other,  or  ulcers  eating  their 
way  through  the  partition  between  them. 

Pathological  Anatomy. — According  to  the  nature  of  the  extraneous 
matter  that  finds  its  way  through  the  fistulas  into  the  genital  canal 
they  are  divided  into  urinary  and  fecal  fistulas. 

A.  Urinary  fistulce  are  again  divided,  according  to  the  organs 
through  which  the  fistula  goes,  into  (1)  vesico-vaginal,  (2)  urethro- 
vaginal,  (3)  uretero-vaginal,  (4)  vesico-uterine,  (5)  vesico-utero-vaginal, 
(6)  ureter  o-uterine,  and  (7)  uretero-vesico-vaginal. 

There  may  be  one  or  more  fistulas,  and  in  size  they  vary  from  a 
scarcely  perceptible  aperture  to  an  opening  measuring  two  inches  in 
diameter. 

1.  Vesico-vaginal  Fistula. — The  most  common  urinary  fistula  is  the 
vesico-vaginal  variety.  The  following  description  applies,  therefore, 
more  particularly  to  it,  and  the  peculiarities  of  the  rarer  forms  will 
be  mentioned  later  on. 

Etiology. — By  far  the  most  common  cause  of  fistula  is  childbirth. 
The  mechanism  maybe  twofold.  The  abnormal  communication  may 
be  due  to  a  tear,  and  appear  immediately  after  delivery,  or  it  may  be 
due  to  pressure  with  consequent  necrosis,  and  not  be  developed  before 
several  days  or  even  weeks  have  elapsed  since  parturition  took  place. 


364  DISEASES  OF  WOMEN. 

Tears  are  especially  found  in  old  primiparse  or  after  the  use  of  ergot  or 
in  cases  in  which  the  forceps  was  applied  before  the  cervix  was  suffi- 
ciently dilated.  Pressure  is  due  to  a  disproportion  between  the  child 
and  the  genital  canal,  a  distended  bladder,  a  loaded  rectum,  a  stone  in 
the  bladder,  abnormal  presentations,  etc.  In  this  connection  it  must 
be  noted  that  the  tissues  withstand  much  better  the  same  degree  of 
pressure  if  it  is  exercised  for  a  shorter  time.  Fistula?  from  pressure 
are,  therefore,  as  a  rule,  not  due  to  the  use  of  forceps,  but  to  improper 
delay  in  their  use.  As  soon  as  the  presenting  part  becomes  impacted 
and  does  not  move  to  and  fro  during  and  between  labor-pains,  artificial 
help  ought  to  be  given  immediately.  In  consequence  of  the  im- 
proved midwifeiy  and  the  much  more  frequent  use  of  the  forceps 
fistula?  have  become  much  rarer  now  than  they  used  to  be,  and  come 
mostly  from  remote  localities  where  proper  assistance  is  not  avail- 
able. 

Fistula?  are  sometimes  due  to  operations,  not  only  the  bungling 
attempt  of  the  ignorant  abortionist,  but  also  in  legitimate  operations 
performed  by  skillful  operators.  Thus  the  formation  of  a  vesico- 
vaginal  fistula  is  a  not  uncommon  accident  in  vaginal  hysterectomy — 
i.  e.  the  removal  of  the  uterus. 

In  rare  cases  foreign  bodies,  such  as  a  pessary  in  the  vagina  or  a 
stone  in  the  bladder,  have  gnawed  a  hole  through  the  partition  be- 
tween the  urinary  and  genital  tract. 

A  pelvic  abscess  opens  sometimes  in  such  a  way  as  to  give  rise  to  a 
urinary  fistula. 

Symptoms. — The  chief  symptom  is  the  more  or  less  constant  drib- 
bling of  urine  from  the  vagina,  but  this  does  not  suffice  for  a  diagno- 
sis, as  the  same  takes  place  if  the  sphincters  of  the  urethra  are  lost 
or  paralyzed,  and,  on  the  other  hand,  if  the  urinary  fistula  is  situated 
high  up,  the  urine  may  be  retained  for  a  long  time  in  the  erect  pos- 
ture, and  in  urethro- vaginal  fistula  it  may  be  entirely  retained  except 
during  voluntary  micturition. 

In  spite  of  the  utmost  cleanliness  fistula  patients  have  a  disagree- 
able ammouiacal  odor.  If  the  fistula  is  large,  it  may  be  felt  by  digi- 
tal examination. 

In  most  cases  it  can  be  seen  by  introducing  a  speculum  and  placing 
the  patient  in  different  positions,  especially  Sims's,  the  genu-pectoral, 
and  the  dorsal  with  elevated  pelvis  (p.  197). 

Sometimes,  however,  the  opening  is  so  minute  that  it  cannot  be 
discovered,  or  it  may  be  hidden  by  a  projecting  cicatrix.  By  inject- 
ing a  colored  fluid — for  instance,  milk — into  the  bladder  the  presence 
of  a  vesico- vaginal  fistula  may  be  established.  A  good  way  to  find 
a  minute  opening  is  to  cover  with  a  piece  of  linen  the  space  within 
which  the  opening  is  supposed  to  be.  Urine  will  go  right  through  it 
and  make  the  linen  wet  (Bozeman).  Sometimes  the  opening  cannot 


DISEASES  OF  THE   VAGINA.  365 

be  made  visible  and  accessible  before  intervening  cicatricial  bands  are 
cut  and  distended  (p.  354). 

Prognosis. — Small  fistula?  heal  sometimes  spontaneously,  even  after 
a  number  of  years.  A  later  pregnancy  has  been  seen  to  effect  a  cure. 
Until  Sims's  time  most  urinary  fistula?  were,  however,  practically  in- 
curable. Now,  on  the  contrary,  the  operations  have  been  brought  to 
such  a  degree  of  perfection  that  very  few  resist  treatment.  It  is,  how- 
ever, quite  frequent  that  two  or  more  operations  are  needed  before 
complete  success  is  obtained.  With  proper  care  the  danger  of  the 
operation  is  very  small. 

Treatment. — The  remedies  at  our  command  are  cleanliness,  cauter- 
ization, and  closure  by  means  of  suture,  either  at  the  fistula  or  at  a 
more  or  less  remote  point. 

1.  Q,eanliness. — A  fresh  fistula,  even  of  considerable  size,  may  be 
much  diminished,  and  sometimes  closed  altogether,  by  giving  hot  vagi- 
nal injections  and  using  remedies  that  render  the  urine  normal.     As 
it  has  a  tendency  to  become  alkaline  and  deposit  phosphates,  acids  are 
indicated,  especially  benzoic,  boric,  nitric,  and  phosphoric.1 

Phosphatic  incrustations  should  be  removed  mechanically,  and 
the  parts  lubricated  with  vaseline  or  zinc  ointment.  Raw  sur- 
faces are  brushed  over  with  a  solution  of  nitrate  of  silver  (gr.  x 
to  3j)  twice  a  week.  Sitz-baths,  once  or  twice  a  day,  are  also  very 
useful. 

2.  Cauterization. — This  method  is  little  used  now-a-days,  since  the 
perfection  of  the  closure  by  suture.     It  may,  however,  be  tried  for 
small  fistula?,  and  is  often  used  successfully,  when  a  small  opening 
remains  or  forms  in  a  stitch-canal  after  the  operation  by  suturing. 

The  part  is  rendered  insensitive  by  means  of  cocaine  (p.  209).  The 
galvano-  or  thermo-cautery  may  be  used.  Among  chemical  caustics, 
the  nitrate-of-silver  stick,  nitric  acid,  carbolic  acid,  and  tincture  of 
cantharides  are  the  best.  The  cauterization  ought  not  to  be  repeated 
until  granulations  have  developed,  and  do  not  grow  any  more.  The 
effect  of  the  cauterization  is  much  enhanced  by  the  use  of  a  permanent 
catheter. 

3.  Closure  by  Suture  at  the  Seat  of  the  Fistula. — This  is  the  most 
reliable  and  satisfactory  of  all  methods.     We  must  consider  sepa- 
rately the  preparatory  treatment,  the  operation,  and  the  after-treat- 
ment, all  of  which  are  of  great  importance  in  effecting  a  cure. 

The  best  time  for  operating  is  six  or  eight  weeks  after  confinement. 

1  Dr.  Emmet  recommends  Acid,  benzoici  ^ij,  Sodii  borat.  ^iij,  Aqu.  ^xii. — M.  Sic;. : 
A  tablespoonful  in  water  three  or  four  times  a  day.  When  the  nrine  has  become  acid 
the  dose  should  be  reduced.  The  benzoates  of  ammonium,  lithium,  or  sodium  (gr. 
v-xxx  have  the  same  effect.  I  have  also  seen  good  effect  of  a  saturated  solution  of 
boric  acid,  a  tablespoonful  four  times  a  day;  8  drops  of  dilute  nitric  acid  in  a  medi- 
cine four  times  a  day ;  and  Horsford's  acid  phosphates,  a  teaspoonful  in  a  wineglass 
of  water,  three  times  a  day. 


366  DISEASES  OF   WOMEN. 

Before  that  period  spontaneous  closures  might  take  place  or  cauteriza- 
tion might  suffice  for  the  purpose.  The  lochial  discharge  would  be 
unfavorable  for  healing  by  first  intention,  and  the  sutures  would  be 
more  liable  to  cut  through  the  friable  tissue.  Later  the  bladder  con- 
tracts and  cicatrices  become  harder. 

The  preparatory  treatment  consists  in  the  same  measures  we  have 
just  mentioned  under  the  heading  of  Cleanliness — namely,  hot  vagi- 
nal douches,  sitz-baths,  acid  medicines,  removal  of  incrustations,  the 
use  of  mild  ointments,  and  painting  with  astringents.  Hairs  that  are 
incrustated  with  urinary  deposits  are  cut  off.  Cicatricial  bands  are 
cut  with  knife  or  scissors  and  the  vagina  dilated  by  the  introduc- 
tion of  a  Bozeman  dilator  (p.  354).  When  the  first  incisions  are 
healed,  new  ones  may  be  made  and  treated  in  the  same  way.  By  this 
combination  of  cutting  and  pressure  not  only  room  is  gained,  which 
renders  the  fistula  more  accessible,  but  the  cicatrical  traction  which  is  a 
serious  obstacle  to  agglutination  is  done  away  with. 

This  local  preparation  may  occupy  from  three  to  five  weeks  or  longer. 

Of  no  less  importance  is  the  general  preparation.  The  patient's  gen- 
eral health  should  be  improved  as  much  as  circumstances  will  permit. 
If  the  fistula  is  due  to  hysterectomy  for  cancer,  it  is  not  worth  while 
trying  to  close  it  until  sufficient  time  has  elapsed  to  prove  that  the  sur- 
rounding tissue  is  healthy.  If  the  patient  has  syphilis,  that  should  first 
be  treated.  Anemic  patients  should  undergo  a  preparatory  tonic  treat- 
ment. Faults  in  the  digestion  should  be  remedied.  Sometimes  a  sea- 
voyage  or  a  sojourn  in  the  country  may  be  a  great  help  in  building  up 
the  debilitated  constitution. 

The  operation  is  performed  according  to  different  methods,  which 
may  be  divided  into  two  groups:  the  denudation  methods  and  tlieflap- 
splitting  methods.  To  the  first  belong  the  methods  of  Sims,  Bozeman, 
and  Simon  ;  to  the  latter  those  of  Blasius  (Tait),  and  Walcher. 

Sims's  Method. — The  patient  is  placed  in  Sims's  position  (p.  137), 
Sims's  speculum,  or  one  of  the  self-holding  modifications  thereof  (p. 
147),  is  introduced.  The  most  dependent  part  of  the  circumference 
of  the  fistula  is  seized  with  a  tenaculum,  and  the  edge  cut  off  all 
around  in  one  strip  with  scissors.  In  so  doing  we  go  close  up  to  the 
mucous  membrane  of  the  bladder  without  implicating  the  same,  as 
that  causes  troublesome  and  sometimes  dangerous  hemorrhage.  If  the 
denuded  surface  is  not  broad  enough,  a  second  strip  is  cut  off  from 
the  vaginal  mucous  membrane  outside  of  and  contiguous  to  the  first 
(p.  337).  The  edges  should  be  brought  together  in  that  direction  in 
which  there  is  least  tension.  At  the  angles  the  denudation  is  carried 
far  enough  away  from  the  fistula  to  include  the  folds  of  mucous  mem- 
brane which  will  be  formed  when  the  edges  of  the  fistula  are  brought 
in  contact.  Thus  even  a  very  small  round  hole  may  necessitate  an 
elliptic  denudation  half  an  inch  wide  and  an  inch  long. 


DISEASES  OF  THE   VAGINA. 


367 


Silver  wire  is  used  for  suturing  (pp.  204  and  218).  It  is  pulled 
through  with  linen  thread.  Round,  slightly  curved  needles  made  cut- 
ting near  the  point  (Fig.  185,  (f)  and  1  inch  long  are  best.  They  are 
introduced  with  Sims' s  needle-holder.  If  possible,  the  needle  is  seized 
below  the  eye,  but  if  the  fistula  is  being  closed  in  a  transverse  line,  the 
needle  must  be  seized  at  its  blunt  end  and  held  in  the  long  axis  of 
the  needle-holder  (Fig.  186,  p.  216).  The  needle  should  be  entered 
about  a  quarter  of  an  inch  from  the  edge  of  the  denuded  surface, 
brought  deep  into  the  tissue,  pushed  out  just  in  front  of  the  mucous 
membrane  of  the  bladder,  and  carried  through  the  corresponding 
points  of  the  opposite  lip.  Five  sutures  are  put  in  for  each  inch  of 
line  of  union.  As  to  the  use  of  the  counter-pressure  hook,  twister, 
suture-shield,  and  cutting  of  wires,  the  reader  is  referred  to  the  general 
rules  given  above  (pp.  219,  220). 

The  patient  is  now  turned  on  her  back,  the  bladder  washed  out 
with  a  double-current  catheter,  and  Sims's  self-retaining,  sigmoid, 
block-tin  catheter  with  many  small  side  openings  introduced.  This 
catheter  should  be  bent  so  as  to  move  freely  behind  the  pubes  as  a 
key  turns  in  a  lock.  Many  now  prefer  soft-rubber  or  glass  catheters. 

After-treatment. — The  patient  should  lie  on  her  back,  at  times 
stretched  out,  at  others  with  a  round  pillow  under  her  knees.  A 
dose  of  opium  is  given  to  relieve  pain,  and  may  be  repeated  several 
times  daily  in  order  to  keep  the  bowels  constipated  for  three  days. 

FIG.  222. 


I/ 


Bozeman's  Operating-Table. 


On  the  fourth  day  the  bowels  are  moved  by  means  of  an  aperient 
and  an  olive-oil  enema  (liv).  The  sutures  are  generally  removed  on 
the  eighth,  ninth,  or  tenth  day. 

The  catheter  is  taken  out  and  cleaned  several  times  a  day.     A 


368 


DISEASES  OF  WOMEN. 


small  flat  cup  (a  bird  bathing-tub)  is  placed  under  it  to  catch  the 
urine  dripping  from  it.  It  is  left  in  a  few  days  after  the  removal  of 
the  sutures.  The  patient  is  allowed  to  sit  up  some  time  during  the 
third  week  after  the  operation. 

FIG.  223. 


Bozernan's  Speculum :  a,  surface  of  third  blade  which  is  applied  to  the  vagina ;  b,  a  short 
plate  which  is  pushed  under  the  ends  c  and  d,  and  thereby  kept  in  place. 

Bozeman's  Method. — Bozeman  places  the  patient  in  the  knee-elbow 
position,  in  which  she  is  retained  by  a  special  apparatus  of  his  (Fig. 
222).  His  speculum  (Fig.  223),  which  allows  one  to  operate  with  less 
assistance  and  throws  light  into  every  part  of  the  vagina,  is  introduced. 
The  denudation  is  made  perpendicularly,  or  so  as  to  form  a  steep 
funnel,  and  comprises  occasionally  the  mucous  membrane  of  the  blad- 
der. He  cuts  with  knife  or  scissors.  He  uses  silver  wires,  but  he 
secures  them  by  means  of  his  button  ;  that  is,  a  small  concave  plate  of 
thin  lead  (Fig.  224)  with  a  hole  for  each  suture.  The  concave  side 
is  pressed  against  the  wound,  a  perforated  shot 
is  pushed  down  over  the  two  ends  of  each  suture, 
and  crushed  with  a  forceps  so  as  to  serve  as  a 
clamp.  The  wires  are  cut  at  a  short  distance 
from  the  shot  and  turned  down  over  its  sides. 

Bozeman  uses  permanent  catheterization,  and 
removes  the  sutures  on  the  seventh  day. 

Simon's  Method. — The  patient  is  placed  in  the 
dorsal  position,  with  raised  pelvis  and  the  legs 
drawn  up — so-called   breech-back   position,   be- 
cause the  breech  presents  as  in  deliveries  with  breech  presentation. 


FIG.  224. 


Bozeman's  Button. 


DISEASES  OF  THE   VAGINA.  369 

Large  broad  specula  and  retractors  are  used,  according  to  circum- 
stances, on  the  anterior,  posterior,  and  lateral  walls.  The  vaginal 
portion  of  the  uterus  is  seized  with  a  volsella  and  pulled  down  to  the 
entrance  of  the  vagina,  where  a  couple  of  strong  threads  are  drawn 
through  it  and  used  to  pull  on  instead  of  the  volsella.  The  edges  are 
cut  off  with  a  knife  perpendicularly  or  in  a  slightly  slanting  direction. 
The  incision  goes  through  the  mucous  membrane  of  the  bladder. 
Fine  silk  is  used  for  the  sutures.  These  are  of  two  kinds,  deep 
relaxing  sutures  and  superficial  uniting  sutures,  which  alternate  with 
each  other.  From  eight  to  ten  are  inserted  for  each  inch  of  union. 
No  catheter  is  left  in  the  bladder.  The  patient  may  urinate  herself 
if  she  can.  Otherwise  the  urine  is  drawn  with  catheter  every  four 
hours.  The  bowels  are  kept  loose.  The  patient  may  lie  in  what 
position  she  prefers,  and  eat  every  thing  she  likes.  If  easily  accessi- 
ble, the  sutures  are  removed  on  the  fourth  or  fifth  day ;  in  difficult 
cases  they  are  left  till  the  sixth  or  seventh  day.  On  the  eighth  day 
the  patient  is  allowed  to  get  up. 

The  Suprapubie  Method. — For  fistula?  that  cannot  be  reached  in 
any  other  way  Trendeleuburg  makes  a  transverse  incision  just  above 
the  symphysis  pubis,  through  the  abdominal  wall.  Next  he  makes 
a  transverse  incision  in  the  bladder,  if  necessary  all  across.  Then  he 
denudes  the  edges  of  the  fistula  and  inserts  silk  sutures,  which  he 
ties  in  the  vagina,  or  catgut  sutures,  which  he  ties  in  the  bladder. 

Biasing's  Method. — This  is  a  flap-splitting  operation  which  has 
been  revived  by  Lawson  Tait  and  others.  Nothing  is  cut  away. 
There  is  merely  made  an  incision  parallel  to  the  vaginal  and  vesical 
mucous  membrane.  This  incision  is  made  on  the  white  line  of  cica- 
trice at  the  edge  to  the  depth  of  from  one-eighth  to  three-eighths  of 
an  inch,  according  to  the  thickness  of  the  septum.  If  the  fistula  is 
small,  it  is  surrounded  by  a  suture  like  the  string  of  a  tobacco-pouch 
in  the  following  way :  a  curved  and  eyed  handled  needle  is  introduced 
through  the  mucous  membrane  of  the  vagina  a  quarter  of  an  inch  out- 
side of  the  lower  end  of  the  incision,  and  made  to  travel  in  the  thick- 
ness of  the  vesico-vaginal  septum  in  a  curved  direction,  following  the 
curve  of  the  separation  of  the  flaps  till  it  comes  to  the  opposite  pole  of 
the  diameter  of  the  fistulous  opening,  and  then  the  point  of  the  needle 
is  made  again  to  emerge  into  the  vagina.  The  needle  is  now  threaded 
and  withdrawn,  one-half  of  the  fistula  being  thus  embraced  by  the 
suture.  The  needle  is  again  made  to  pass  similarly  round  the  oppo- 
site half  of  the  fistula,  the  points  of  ingress  and  egress  being  identical 
with  those  of  the  first  half  of  the  proceeding.  The  needle  is  again 
threaded  and  withdrawn,  and  in  this  way  the  circumvention  of  the 
fistula  is  completed.  When  the  thread  or  wire  is  drawn  tight  and 
secured,  it  will  be  found  that  the  flap  of  vaginal  mucous  membrane  is 
made  to  front  into  the  vagina,  and  that  of  the  vesical  mucous  mem- 

24 


370 


DISEASES  OF  WOMEN. 


FIG.  225. 


brane  to  front  correspondingly  into  the  bladder,  whilst  the  raw  sur- 
faces between  them  are  brought  fully  together. 

If  the  fistula  is  so  large  that  it  is  advisable  to  close  it  in  a  linear 
direction,  the  needle  is  made  to  enter  the  raw  surface  of  the  vaginal 
flap  at  the  line  of  incision,  burying  it  deeply  in  the  tissue  of  the  sep- 
tum just  beyond  the  point  of  division  of  the  limbs  of  the  V  formed 
by  the  incision,  and  bringing  it  out  on  the  corresponding  point  of  the 
posterior  limb  of  the  same  V.  The  needle  is  then  threaded  and  with- 
drawn. Next,  the  needle  is  pushed  in  the  same  way  through  the 
two  limbs  of  the  V  on  the  other  side — i.  e.  the  anterior  and  posterior 
flap ;  it  is  threaded  with  the  distant  end  of  the  first  thread  and  pulled 
back.  When  such  threads,  in  sufficient  number,  are  placed  parallel 
to  one  another,  the  sutures  are  closed.  Tait  uses  always  silver  wire. 
He  says  it  is  generally  much  easier  to  insert  the  sutures  by  means  of 
the  forefinger  guiding  the  needle  without  any  speculum  than  with  the 
assistance  of  the  latter  instrument.1 

Watcher's  Method  (Fig.  225). — All  cicatricial  tissue  is  cut  away, 

sparing  as  much  as  possible  all  healthy 
mucous  membrane.  When  the  cica- 
tricial tissue  is  thoroughly  removed 
the  edges  of  the  fistula  acquire  an 
astonishing  mobility,  and  can  be  ap- 
plied to  one  another  without  tension. 
On  the  place  most  remote  from  the 
field  of  operation,  on  the  side  turned 
toward  the  bladder,  he  makes  a  super- 
ficial incision  around  the  cicatricial 
edge  of  the  fistula.  Next  he  makes 
a  similar  incision  around  the  cicatrix 
in  the  vagina,  and  then  he  cuts  out 
the  whole  cicatrix  as  deep  as  possible. 
In  some  places  larger  cieatricial  masses 
have  to  be  removed ;  in  others,  where 
healing  had  taken  place  by  first  inten- 
tion, the  edge  is  simply  split  into  an 
anterior  and  posterior  flap.  As  long 
as  there  are  immovable  parts  or  parts 
moved  with  difficulty,  the  cicatricial 
tissue  has  to  be  removed  or  cut  through. 
Finally,  the.  wall  of  the  bladder  be- 
comes so  movable  that  in  many  cases 
it  can  be  pulled  out  through  the  wound 
Now  the  vesical  flaps  are  brought  together  in  a  line 
He  introduces  the  needle  on  the  raw 


Walcher's  Fistula  Operation :  a,  fistula ; 
b,  bladder ;  c,  vaginal  wall  rolled  out. 


like  a  loose  sac. 

by  a  row  of  catgut  sutures. 


1  L.  Tait,  The  British  Gynecological  Journal,  Nov.,  1887,  Part  xi.  p.  368. 


DISEASES  OF  THE   VAGIXA.  371 

surface  a  quarter  of  an  inch  from  the  fistula,  and  pushes  it  out  on  the 
line  of  demarkation  between  the  raw  surface  and  the  raucous  mem- 
brane of  the  bladder,  just  comprising  the  latter  in  the  suture  (compare 
submucous  sutures,  p.  316).  Next,  the  needle  is  carried  through  the 
corresponding  points  on  the  other  side.  When  all  the  sutures  are  in 
place  they  are  tied.  After  thus  closing  the  bladder  the  vaginal  flaps 
are  united  in  a  line  above  the  other  by  means  of  silk  sutures. 

The  Abdominal  Method. — Vesico- vaginal  fistula?  so  situated  that  it 
is  impossible  to  reach  them  from  the  vagina  have  been  operated  on  by 
performing  laparotomy  and  separating  the  bladder  from  the  uterus 
and  the  vagina.. 

Dangers  and  Difficulties. — With  ordinary  care  there  is  not  much 
danger  of  sepsis.  In  operations  near  the  fornix  the  peritoneal  cavity 
may  be  opened — an  accident  which  used  to  be  much  dreaded,  but  now 
has  lost  most  of  its  importance. 

Primary  hemorrhage  may  be  quite  considerable.  Often  it  may  be 
arrested  by  injecting  hot  or  ice-cold  water  into  the  bladder  and  the 
vagina,  or  by  temporary  pressure,  but  sometimes  it  may  become 
necessary  to  ligate  an  artery.  This  may  be  done  by  inserting  a  silver 
wire  through  the  vaginal  wall  so  as  to  embrace  the  bleeding  vessel, 
which  experience  has  shown  usually  comes  from  the  neck  of  the 
bladder  or  the  neck  of  the  womb  (T.  A.  Emmet). 

Secondary  hemorrhage  is  very  rare.  Bloodclots  in  the  bladder 
should  be  broken  up  with  catheter  or  dull-wire  curette.  Hot  and 
ice-cold  injections  should  be  made.  If  these  measures  do  not  check 
the  hemorrhage,  the  sutures  must  be  removed  and  the  bleeding  vessel 
looked  for  and  tied. 

One  of  the  greatest  dangers  in  fistula  operations  is  that  of  injuring 
or  ligating  the  ureters.  The  first  accident  may  lead  to  the  formation 
of  a  uretero-vaginal  fistula  more  difficult  to  heal  than  the  original 
vesico-vaginal  fistula.  The  ligation  of  a  ureter  leads  to  acute  hydro- 
nephrosis  with  high  fever  and  vomiting.  If  the  field  of  operation 
extends  more  than  half  an  inch  from  the  median  line,  the  operator 
should  look  out  for  the  ureter.  Sometimes  it  can  be  seen  at  the  edge 
of  the  fistula.  Then  the  ureter  must  first  be  split  open  from  the 
bladder  to  the  extent  of  half  an  inch  and  the  edges  of  the  wound 
allowed  to  heal  separately,  so  as  to  throw  the  mouth  of  the  ureter 
further  back  into  the  bladder  before  the  fistula  is  closed. 

The  operator  should  note  the  number  of  sutures  he  introduces  and 
be  sure  to  remove  them  all,  as  an  overlooked  or  cut-off  suture  may 
form  the  nucleus  of  a  calculus  in  the  bladder. 

When  there  is  great  loss  of  substance  it  is  often  impossible  to  unite 
the  edges  on  one  line.  It  may  then  become  necessary  to  give  to  the 
line  of  union  the  shape  of  a  Y,  a  T,  or  an  I . 

In  large  fistulse  it  is  also  sometimes  found  advantageous  not  to 


372  DISEASES  OF   WOMEN. 

denude  the  whole  edge  at  once,  but  to  operate  in  sections,  paring  and 
uniting  one  part  before  the  next  is  taken  hold  of.  In  this  way  much 
blood  may  be  saved  and  the  field  kept  clean. 

Long  tine  fistulse  in  front  of  the  cervix  have  been  closed  by  fresh- 
ening the  surface  with  a  dentist's  engine,  substituting  cutting  edges 
for  the  blunt  ones,  and  approximating  the  vivified  walls  with  deep 
sutures.1 

If  the  fistula  is  situated  near  the  bone  the  flap-splitting  operations 
may  hold  out  the  best  prospects  for  effecting  a  cure. 

Before  removing  the  sutures  it  may  be  well  to  try  if  the  fistula  is 
closed  by  injecting  a  little  milk  into  the  bladder.  If  the  edges  and 
stitches  look  healthy  and  there  is  a  leakage,  complete  closure  may  be 
obtained  by  leaving  the  sutures  in  for  a  day  or  two  longer. 

Combination  of  Methods. — By  a  judicious  combination  of  the  best 
features  of  the  operations  described  above  an  operator  may  obtain 
better  results  than  by  adhering  tenaciously  to  the  rules  laid  down  by 
one  of  the  inventors  of  methods.  Preparatory  cutting  and  stretching 
of  cicatrices  are  of  great  importance.  Bo/eman's  or  Simon's  position 
give  sometimes  better  access  to  the  fistula  than  Sims's.  It  is  often  impos- 
sible to  pull  the  fistula  down  so  as  to  operate  near  the  vaginal  entrance, 
as  prescribed  by  Simon.  The  dislocation  of  the  uterus  may  give  rise 
to  pelvic  hemorrhage  or  inflammation.  It  is,  therefore,  better  to  ope- 
rate in  situ,  and  for  this  silver  wire  is  much  preferable  to  any  other 
material.  The  largest  speculum  that  finds  room  should  be  used,  but,  as 
a  rule,  the  larger  the  fistula  the  smaller  the  speculum  must  be.  The  per- 
manent catheter  is  liable  to  cause  cystitis,  which  again  interferes  with 
healing  by  first  intention.  It  is  also  very  uncomfortable  for  the  patient 
to  lie  constantly  on  her  back.  The  introduction  of  a  hard  catheter 
has  sometimes  mechanically  interfered  with  healing.  If  the  bladder 
has  retained  a  reasonable  degree  of  capacity,  it  is  better  to  let  the 
patient  urinate  or  draw  the  urine  with  a  velvet-eye,  soft  rubber  catheter. 
But  in  large  fistulse  with  great  retraction  of  the  bladder  the  use  of  the 
permanent  catheter  is  preferable.  It  is  a  decided  advantage  to  keep 
the  bowels  open  and  let  the  patient  take  plenty  of  substantial  food. 

2.  Urethro-vaginal  Fistula. — In  this  kind,  the  wall  of  the  septum 
being  very  thin,  the  denudation  must  be  extended  over  the  nearest 
part  of  the  vagina.  The  edges  are  brought  together  from  side  to 
side  over  a  metal  catheter,  and  if  the  tension  is  great,  an  incision  is 
made  on  both  sides  parallel  to  the  line  of  union. 

Atresia  of  the  upper  part  of  the  urethra  may  be  combined  with  a 
vesico-vaginal  fistula.  Then  the  closed  canal  may  be  perforated  with 
a  trocar  and  kept  open  by  the  daily  use  of  sounds.  Another  method 
is  to  cut  out  the  closed  portion  of  the  urethra  and  unite  the  lower  to 
the  neck  of  the  bladder. 

1  Thomas,  Diseases  of  Women,  6th  ed.  p.  274. 


DISEASES  OF  THE   VAGINA.  373 

If  the  atresia  is  situated  between  a  urethral  and  a  vesico- vaginal 
fistula,  the  occluded  position  is  bridged  over  by  uniting  the  upper 
edge  of  the  vesical  fistula  with  the  lower  of  the  urethral,  or  if  the 
loss  of  substance  at  the  base  of  the  bladder  is  so  great  that  this  can- 
not be  done,  or  would  cause  so  much  tension  on  the  urethra  that 
incontinence  would  follow,  an  artificial  transverse  vesico-vagiual  fistula 
is  made  just  above  the  neck  of  the  bladder,  between  the  two  other 
fistulse.  The  upper  edge  of  this  artificial  fistula  is  stitched  to  the 
lower  edge  of  the  urethral  fistula,  and  after  healing  has  taken  place, 
the  edges  of  the  original  vesico-vaginal  fistula  are  brought  together 
from  side  to  side. 

The  whole  urethra  may  be  destroyed  and  may  be  restored  by  bor- 
rowing tissue  from*  the  surrounding  mucous  membrane  (compare  p. 
255). 

3.  Uretero-vaginal  Fistula. — Remembering  the  relations  between 
the  ureter,  the  neck  of  the  womb  and  the  fornix  of  the  vagina  (p.  81), 
we  can  easily  imagine  how  a  fistula  may  be  formed  between  the  ureter 
and  the  uterus  or  the  ureter  and  the  vagina,  but  it  is  fortunate  such 
•communications  are  rare,  since  they  are  difficult  to  cure. 

A  uretero-vaginal  fistula  is  situated  on  the  anterior  wall  of  the 
vagina,  a  little  below  and  outside  of  the  vaginal  portion  of  the  ute- 
rus. It  is  distinguished  from  a  vesico-vaginal  fistula  by  introducing 
an  elastic  catheter,  which,  if  the  fistula  is  ureteral,  can  be  pushed 
deep  in  in  the  direction  of  the  corresponding  kidney,  and  urine  will 
be  secreted  in  jets  from  it.  Milk  injected  through  the  urethra  will 
come  out  immediately  through  the  fistula  if  it  is  vesico-vaginal,  but 
will  not  pass  through  a  ureteral  fistula.  Often  that  part  of  the  ureter 
which  is  situate  between  the  fistula  and  the  bladder  becomes  obstructed. 
If  under  such  circumstances  the  fistula  were  closed,  acute  hydronephro- 
sis  with  all  its  dangers  would  be  the  result.  The  perviousness  of  rho 
lower  portion  of  the  ureter  is  made  out  by  introducing  one  probe 
through  the  fistula  and  an  another  through  the  urethra,  which  will 
come  in  contact  in  the  bladder  if  there  is  free  communication  between 
the  fistula  and  that  organ. 

The  causes  of  uretero-vaginal  fistula  are  pressure  during  child- 
birth, the  gnawing  of  a  pessary,  hysterectomy,  or  the  operation  for 
a  vesico-vaginal  fistula,  in  consequence  of  which  the  ureter  may  be 
injured. 

Treatment — Three  operations  are  available :  closure  of  the  fistula, 
implantation  of  the  ureter  in  the  bladder,  or  nephrectomy. 

A.  Closure  of  the  Fistula. — The  fistula  has  been  directly  closed  in 
different  ways. 

a.  Bandl's  Method  (Fig.  226). — Bandl  made  an  elliptic  incision 
around  the  fistula  in  the  course  of  the  ureter,  cut  out  some  tissue  at  the 
lower  end  of  this  incision  and  made  an  opening  into  the  bladder,  press- 


374 


DISEASES  OF  WOMEN. 


ing  it  out  from  behind  with  a  sound.     Next  he  introduced  a  fine 
flexible  catheter  (French  No.  2)  into  the  bladder  through  the  urethra, 

FIG.  226. 


Diagram  of  Bandl's  Operation  for  Uretero- vaginal  Fistula  (the  patient  is  in  geuu-pectoral  pos- 
ture): SS,  vaginal  wall;  V,  line  of  union  after  closing  a  vesico-vaginal  fistula  in  a  pre- 
vious operation,  which  had  led  to  the  formation  of  the  uretero-vaginal  fistula;  B,  bladder; 
U,  vaginal  portion  of  uterus;  H,  right  ureter ;  H',  left  ureter  opening  at  a  into  the  vagina; 
cc,  first  incision  ;  de,  flat  denudation  in  the  vagina :  6.  artificial  opening  into  the  bladder. 

drew  its  point  with  a  forceps  through  the  artificial  opening  made  i» 
the  bladder,  out  into  the  vagina,  and  pushed  it  into  the  ureter.  Next 
he  denuded  the  vagina  outside  of  the  first  line  of  incision  and  brought 
the  raw  surfaces  together  with  four  silver  wire  sutures,  over  the  cath- 
eter. He  used  Bozeman's  position,  speculum,  and  button,  and  left 
another  catheter  in  the  bladder.1 

b.  Schede's  Method.2 — Schede  cut  out  an  oval  piece  of  the  vesico- 
vaginal  septum  with  an  area  of  three-quarters  of  an  inch  square  and 
having  the  opening  of  the  ureter  at  its  upper  end,  and  stitched  the 
vesical  and  the  vaginal  mucous  membranes  together.  Two  weeks 
later  he  introduced  a  flexible  catheter  with  the  eye-end  into  the  ureter 
and  with  the  other  into  the  bladder,  whence  he  pulled  it  out  through 
the  urethra.  Like  Bandl,  he  left  a  narrow  strip  of  undenuded  tissue 

1  Ludwig  Bandl,  Die  Bozemamche  Methode  der  Blasenscheidenftstel- Operation  und 
Beitrage  zur  Operation  der  Hamleiter-und  Blasemcheidenfisteln,  Wien,  1883,  p.  42. 

*  For  the  difficulties  he  met  with  before  he  obtained  success  the  reader  is  referred 
to  his  own  article  in  Centralbl.  f.  Gyndk.,  1881,  vol.  v,  p.  549. 


DISEASES  OF  THE   VAGINA.  375 

round  the  ureteral  fistula,  denuded  outside  of  this,  and  closed  the 
fistula. 

c.  Pozzi's  Method. — Pozzi  used  the  flap-splitting  method  in  a  case 
of  uretero-vesico- vaginal  fistula.  He  placed  the  patient  in  the  knee- 
chest  position,  made  a  transverse  incision  extending  half  an  inch 
beyond  the  borders  of  the  vesico- vaginal  fistula  and  a  perpendicular  at 
each  end  so  as  to  form  an  H.  Next  he  dissected  the  two  flaps  off  to 
a  distance  of  half  an  inch,  brought  them  together  over  the  openings  of 
both  fistulse  with  three  deep  silver-wire  sutures  and  three  superficial 
sutures.1 

B.  Implantation  of  the  Ureter  in  the  Bladder  ( Uretero-cystostomy). 
— This  may  be  accomplished  by  the  iutraperitoneal  or  by  the  extra- 
peritoneal  method. 

a.  The  Intra-peritoneal  Method. — The  abdomen  is  opened  in  the 
median  line  as  in  other  laparotomies.  The  ureter  is  dissected  out, 
and  an  opening  made  in  the  posterior  wall  of  the  bladder  by  cutting 
down  on  a  closed  forceps  introduced  through  the  urethra.  A  thin 
flexible  catheter  is  introduced  into  the  ureter  and  pulled  out  through 
the  urethra.  The  ureter  is  then  fastened  to  the  wall  of  the  bladder 
by  means  of  interrupted  silk  sutures.  A  self-retaining  soft-rubber 
catheter  is  inserted  through  the  urethra  into  the  bladder  beside  the 
ureteral  catheter;  and  finally  the  abdomen  is  closed. 

6.  The  Extra-peritoneal  Method. — In  order  to  avoid  the  dangers  of 
intestinal  occlusion  if  the  ureter  forms  a  cord  drawn  through  the  cav- 
ity of  the  pelvis,  a  method  has  been  invented  by  which  the  ureter  is 
displaced,  and  the  bladder  drawn  up  toward  it  outside  of  the  perito- 
neum.2 The  patient  is  placed  in  Trendelenburg's  position.  Median 
laparotomy  is  performed.  Next,  a  small  incision  is  made  through  the 
peritoneum  where  the  ureter  crosses  the  bifurcation  of  the  iliac  artery 
(p.  81),  in  doing  which  the  surgeon  must,  however,  bear  in  mind  that 
the  ovarian  vessels  lie  in  front  of  the  ureter  at  this  place.  By  pulling 
on  the  ureter  here  he  makes  its  lower  course  apparent,  and  makes  a 
second  small  incision  through  the  broad  ligament  about  the  middle 
of  its  height.  Through  this  he  pulls  the  ureter  out,  ties  it  with  a  double 
ligature,  and  cuts  it  across  on  a  little  pad.  The  protruding  mucous 
membrane  of  the  lower  end  is  cut  off,  the  peritoneum  sutured  over  the 
opening,  and  the  stump  dropped.  The  upper  end  of  the  severed  ureter 
is  pushed  behind  the  peritoneum  up  to  the  upper  opening,  where  it  is 
seized  with  a  long  narrow  forceps,  which  is  carried  from  the  side  of  the 
bladder,  outside  of  the  peritoneum,  above  the  ilio-pectineal  line,  and 
from  where  it  is  pulled  down.  Next,  the  two  small  openings  in  the  peri- 
toneum and  the  incision  in  it  in  the  median  line  are  closed  with  fine  cat- 
gut. The  bladder,  distended  with  a  small  quantity  of  boric-acid  solution, 

1  Pozzi,  Traite  de  Gynecologic  cliniqueet  operatoire,  Paris,  1890,  p.  934. 

2  O.  Witzel  of  Bonn,  Centralbl.  fur  GynaJc.,  1896,  vol.  xx.  No.  11,  p.  290. 


376  DISEASES  OF  WOMEN. 

is  now  easily  drawn  up  toward  the  ureter  until  they  are  in  contact  in  the 
length  of  an  inch  and  a  half.  The  end  of  the  ureter  is  cut  slantingly, 
and  a  small  hole  is  made  in  the  wall  of  the  bladder  by  cutting  down 
on  a  catheter  introduced  through  the  urethra,  and  the  mucous  mem- 
brane of  the  ureter  is  stitched  with  fine  catgut  to  that  of  the  bladder, 
and  then  the  wall  of  the  ureter  is  stitched  to  the  sides  of  the  hole  in 
the  wall  of  the  bladder.  The  bladder  is  raised  in  two  folds  above 
and  below  the  ureter,  and  these  folds  are  stitched  together  over  it,  so 
as  to  form  an  oblique  canal  one  and  a  half  inch  long,  simulating  the 
normal  obliquity  of  the  course  of  the  ureter  through  the  wall  of  the 
bladder.  A  small  drain  is  left  in  an  opening  cut  through  the  skin 
corresponding  to  the  place  of  union  between  bladder  and  ureter. 
Finally,  the  abdominal  wound  is  closed,  and  a  catheter  left  in  the 
bladder  for  four  days. 

C.  Nephrectomy.     (See  below,  under  Uretero-uterine  Fistula.) 

Of  these  three  operations  the  closure  of  the  fistula,  as  the  safest  and 
simplest,  should  first  be  tried.  The  implantation  of  the  ureter  in  the 
bladder  has  given  good  results  in  several  cases,  and  should  be  pre- 
ferred to  the  mutilating  nephrectomy. 

4.  Vesico-uterine  Fistula. — Fistulous  communication  between  the 
urinary  system  and  the  uterus  can  only  take  place  in  the  cervix. 
The  other  end  of  the  fistula  may  be  in  the  bladder  or  in  the  ureter, 
and  it  is  of  vital  importance  to  distinguish  between  these  two  condi- 
tions. Common  for  both  is  the  discharge  of  urine  from  the  os  uteri. 
The  vesico-cervical  fistula  forms  a  small  round  hole  opening  in  the 
middle  of  the  cervix,  a  condition  which  has  been  brought  about  by 
imperfect  healing  of  a  tear  through  the  anterior  wall  of  the  cervix 
and  the  base  of  the  bladder. 

Diagnosis. — Sometimes  a  probe  can  be  brought  from  the  bladder 
through  the  fistula  into  the  cervical  canal,  where  it  comes  in  contact 
with  a  uterine  sound  held  there.  Milk  injected  into  the  bladder  will 
come  out  of  the  os  uteri.  If  the  cervical  canal  is  plugged  with  a 
lamiuaria  tent,  no  systemic  disturbance  will  result,  while  acute  hydro- 
nephrosis  is  developed  if  it  is  a  uretero-cervical  fistula. 

Prognosis. — This  kind  of  fistula  has  an  unusual  tendency  to  spon- 
taneous healing,  which  probably  is  due  to  the  thickness  of  the  wall 
in  which  it  is  situated. 

Treatment. — This  tendency  to  spontaneous  closure  may  be  furthered 
by  cauterization.  If  that  does  not  succeed,  closure  by  suture  may  be 
attempted  in  different  ways. 

a.  Emmet's  Method. — The  anterior  lip  of  the  cervix  is  split  open  in 
the  median  line,  so  as  to  reproduce  a  condition  similar  to  that,  obtain- 
ing when  the  injury  was  fresh.     In  this  way  the  fistula  is  reached,  and 
pared,  and  the  wound  united  by  silver-wire  sutures  from  side  to  side. 

b.  Fold's  Method. — The  urethra  is  dilated  so  as  to  admit  the  index- 


DISEASES  OF  THE   VAGINA,  377 

finger,  and  the  cervix  is  pulled  down  to  the  vaginal  entrance.  A 
transverse  incision  is  made  in  front  of  the  cervix,  the  bladder  dis- 
sected off,  and  the  opening  in  the  bladder  closed,  the  finger  in  the 
urethra  aiding  the  introduction  of  the  sutures. 

It  seems  that  even  the  somewhat  risky  dilatation  of  the  urethra 
(p.  142)  may  be  dispensed  with.1 

As  a  last  resort  the  cervix  may  be  turned  into  the  bladder  by 
suturing  it  to  the  borders  of  a  hole  cut  from  the  vagina  into  the 
bladder. 

5.  Vesico-utero- vaginal  Fistula. — This  fistula  goes  from  the  blad- 
der through  the  anterior  lip  of  the  cervix  and  ends  in  the  vagina. 

Treatment. — If  there  is  left  enough  of  the  anterior  lip  of  the  cervix 
a  denudation  is  made  here  and  stitched  together  with  a  correspond- 
ingly pared  surface  on  the  anterior  wall  of  the  vagina. 

If  there  is  not  tissue  enough  left  in  front  the  posterior  lip  of  the 
cervix  is  pared  and  brought  together  with  the  anterior  lip  of  the 
opening  in  the  bladder.  By  this  procedure  the  cervix  is  turned  into 
the  bladder,  and  the  menstrual  flow  is  secreted  with  the  urine  through 
the  urethra. 

6.  Uretero-uterine  Fistula. — In  this  variety,  as  in  the  vesico-ute- 
rine,  urine  flows  from  the  os,  but  the  exact  condition  can  be  made 
out  in  different  ways.     Milk  injected  into  the  bladder  will  not  come 
out  through  the  os.     If  the  cervical  canal  is  plugged  there  will  soon 
appear  symptoms  of  acute  hydronephrosis,  such  as  pain  in  the  lumbar 
region,  vomiting,  and  fever.     The  most  conclusive  test  is,  however, 
that  of  Berard.     The  bladder  is  emptied  with  catheter,  and  the  patient 
is  placed  on  a  vessel  that  will  collect  all  the  urine  coming  from  the 
vagina.     At  the  end  of  two  hours  the  urine  is  again  drawn  from  the 
bladder  by  means  of  a  catheter.     The  amount  obtained  will  equal 
that  which  has  flowed  from  the  vagina,  each  being  the  secretion  of 
one  ureter.     The  ureter  may  perhaps  be  felt  swollen  (p.  167).     That 
it  should  be  possible  to  introduce  a  ureter-catheter  into  the  uterus 
from  the  bladder  (p.  165)  is  very  unlikely. 

This  variety  of  fistula  is  exceedingly  rare. 

Treatment. — The  cervix  must  be  turned  into  the  bladder  as  de- 
scribed above.  As  the  lower  portion  of  the  ureter  is  usually  oblit- 
erated, it  is  not  allowable  simply  to  close  the  os  uteri,  apart  from  the 
trouble  that  might  be  anticipated  by  the  stagnation  of  urine  in  the 
uterus. 

Another  method  more  dangerous,  but  offering  the  advantage  of 
not  interfering  with  fertility,  consists  in  nephrectomy ;  that  is,  the 
removal  of  the  corresponding  kidney  through  an  incision  made  in 
the  lumbar  region  (Simon). 

7.  Uretero-vesico-vaginal  Fistula. — When  the  ureter  has  been  partly 

1  A,  Benckisser,  Centrcdblatt  f.  Gynak.,  1893,  vol.  xvii.  p.  847. 


378  DISEASES  OF  WOMEN. 

destroyed  at  the  same  time  as  a  vesico-vaginal  fistula  is  formed,  the 
opening  of  the  former  is  found  somewhere  on  the  edge  of  the  latter. 
We  have  seen  above  how  this  condition  may  be  cured,  either  with  or 
without  slitting  up  the  ureters. 

Genital  Clems. — When  it  is  impossible  to  close  a  fistula,  relief 
from  the  troublesome,  constant  escape  of  urine  may  be  afforded  by 
closing  the  genital  canal  below  the  seat  of  the  fistula,  an  operation 
called  cleisis,  or  closure. 

We  have  already  alluded  to  the  closure  of  the  uterine  os  (hystero- 
cleisis),  the  turning  in  of  the  cervix  into  the  bladder  (hystero-cysto- 
cleisis).  The  vulva  may  be  made  the  seat  of  the  closure  (episio-deisis), 
but  this  is  a  very  objectionable  procedure,  since  it  not  only  renders 
impregnation  impossible,  but  prevents  coition,  causes  stagnation  of 
urine,  and  may  give  rise  to  the  formation  of  stone  in  the  lower  part  of 
the  vagina.  The  most  common  seat  of  this  closure  is  the  vagina 
(colpodeisis).  In  performing  this  operation  the  operator  should 
always  keep  in  view  the  desirability  of  preserving  as  much  of  the 
depth  of  the  vagina  as  possible.  Closure  should  therefore  not  be 
made  at  a  lower  point  than  necessary,  and  often  much  can  be  gained 
by  giving  the  line  of  union  a  slanting  direction. 

The  patient  is  placed  in  Simon's  position  (p.  368).  A  narrow  strip 
is  cut  off  from  the  mucous  membrane  of  the  vagina  in  such  a  way  that 
the  denuded  part  of  the  anterior  wall  fits  to  that  of  the  posterior. 
These  are  now  brought  together  by  sutures  according  to  general  rules. 
During  the  insertion  of  sutures  on  the  anterior  wall  a  sound  is  kept 
in  the  bladder,  and  while  working  on  the  posterior  wall  the  operator 
uses  a  finger  in  the  rectum  as  a  guide. 

Through  the  development  of  better  methods  for  the  direct  closure 
of  urinary  fistula,  the  use  of  genital  cleisis  has  become  more  and  more 
rare.  Still,  the  operation  is  yet  occasionally  indicated  in  cases  of 
great  loss  of  substance,  when  there  is  much  cicatricial  tissue  around 
the  fistula  partly  adherent  to  the  bone,  when  the  bladder  is  inverted 
and  filled  with  part  of  the  intestine,  and  especially  in  certain  cases  of 
uretero-uterine  and  vesico-utero- vaginal  fistula.  (See  above.) 

When  the  urethra  had  been  lost  or  its  lower  edge  was  too  weak  to 
be  pared  and  stitched,  Von  Nussbaum  combined  cleisis  with  the 
formation  of  an  artificial  supra-pubie  urethra.  He  punctured  the 
bladder  above  the  symphysis,  and  left  the  canula  in  place  for  two 
weeks.  Then  the  patients  were  allowed  to  get  up,  and  directed  to 
empty  the  bladder  every  two  or  three  hours  with  a  female  catheter. 
At  the  end  of  a  few  months  the  catheter  could  be  dispensed  with,  the 
urine  being  driven  out  at  will,  in  a  jet,  by  contraction  of  the  abdom- 
inal muscles.  In  the  interval  the  recti  and  pyramidales  muscles  kept 
the  little  opening  closed. 

Urinals. — If  for  some  reason  or  other  no  operation  can  be  per- 


DISEASES  OF  THE   VAGINA.  379 

formed,  the  patient  may  derive  more  or  less  comfort  from  the  use  of 
a  urinal.  These  may  be  divided  into  two  classes,  the  extra-  and 
intra-vaginal.  To  the  first  belong  rubber  bags  with  a  wide  opening 
covering  the  vulva,  and  fastened  to  the  pelvis  and  the  thigh.  To  the 
second  belong  the  ingenious  apparatus  of  Bozeman  and  Jay.  Boze- 
man's  consists  in  a  flat  pear-shaped  receiver  of  silver  with  a  number 
of  holes  on  the  side  that  comes  in  contact  with  the  anterior  vaginal 
wall.  The  urine  enters  through  one  or  more  of  these  holes,  and  is 
led  through  a  tube  to  a  rubber  bag  attached  to  the  thigh.  Jay's  con- 
sists in  a  strong  soft-rubber  ring,  to  which  is  attached  a  bag  of  the 
same  material,  ending  in  a  tube  which  is  compressed  by  a  shut-off. 
The  ring  is  introduced  into  the  vagina  where  it  stays  by  its  own 
expansion.  The  patient  takes  a  daily  sitz-bath,  and  slips  the  nozzle 
of  a  syringe  into  the  exit-tube  and  fills  the  urinal  repeatedly  with 
warm  soap-suds.1 

I  have,  however,  found  that  patients,  for  different  reasons,  such  as 
pain,  excoriations,  lack  of  coaptation,  get  tired  of  wearing  urinals  and 
prefer  to  protect  themselves  with  towels. 

Operations  for  Incontinence. — It  happens  sometimes,  after  a  com- 
plete closure  of  a  fistula,  that  the  patient  continues  having  a  con- 
stant dribbling  of  urine,  which  now  escapes  involuntarily  through 
the  urethra.  This  condition  may  be  due  to  the  loss  of  the  sphincter 
muscles  of  the  urethra,  or  to  traction  being  exercised  on  the  urethra, 
by  which  it  is  kept  open,  or  simply  to  the  habit  of  contraction  acquired 
by  the  bladder  while  the  fistula  was  open.  Sometimes  a  spontaneous 
cure  takes  place  by  shrinkage  of  a  cicatrix  running  across  the  neck 
of  the  bladder;  but  this  is  at  best  slow  work.  Pawlik2  has  devised 
an  operation  by  which  the  condition  is  remedied  at  once  (Fig.  227). 
The  patient  is  placed  in  knee-elbow  po- 
sition. The  urethra  is  pulled  to  one  side 
with  a  tenaculum  as  far  as  possible  (a). 
The  limits  of  the  fold  thus  formed  are 
marked  on  the  mucous  membrane.  From 
these  points  two  parallel  lines  are  drawn 
up  and  made  to  converge  at  their  upper 
end  near  the  subpubic  ligament.  Next 
the  meatus  is  pulled  as  far  as  possible  Pawlik,s  operation  for  mconti- 

tOWard    the    clitoris    without    Using    Undue  nence:  //,  urethra;  A    denuda- 

i       i    /IN         rr<i  tlon'     a<    point    to    which     the 

force,   and    that    point    marked    (6).       Ihe  urethra  can  be  pulled  to  a  side  : 

I-  n   •       •   •  ,•          j    •  6,  point  to  which  it  can  he  pulled 

lines  oi  incision  are  now  continued  in  a       in  the  direction  of  the  clitoris. 

slightly  convergent  direction  to  b.     The 

thus  circumscribed  tissue  is  cut  out  in  the  shape  of  a  wedge,  and  the 

1  John  C.  Jay,  Jr.,  New  York  Medical  Record,  Aug.  28,  1886,  vol.  xxx.  p.   251. 
The  urinal  is  made  by  Parker,  Stearns  &  Sutton,  228  South  street,  New  York. 

2  Pawlik,  Wiener  Med.  Wochenschrift,  1883,  Nos.  25-26,  p.  772,  and  Zeilschrift  fur 
Geburtshiilfe  und  Gynak.,  1882,  vol.  viii.  p.  38. 


380  DISEASES  OF  WOMEN. 

wound  united  with  deep  sutures  of  carbolized  silk  and  covered  with 
iodoform.  After  seven  days  the  sutures  are  removed,  and,  the  wound 
having  healed  by  first  intention,  the  other  side  is  treated  in  the  same 
way. 

The  object  of  this  operation  is  to  stretch  the  urethra  from  side  to 
side,  and  at  the  same  time  to  bend  it  in  the  direction  of  the  clitoris, 
by  which  double  process  its  posterior  and  anterior  walls  are  brought 
in  contact. 

The  same  operation  may  be  performed  when  the  urethra  is  gaping 
and  the  patient  suffers  from  incontinence  without  having  had  a  fistula. 

Sometimes  the  cause  of  incontinence  is  irritation  caused  by  a  band 
attached  to  the  urethra  and  spreading  itself  over  the  anterior  aspect 
of  the  vulvo-vagiual  junction.  A  cure  may  then  be  effected  by  clip- 
ping this  band.  In  other  cases  wings  of  mucous  membrane  are  found 
attached  to  the  urethra.  The  treatment  consists  in  their  excision  and 
union  of  the  wound  by  interrupted  sutures.  In  still  other  cases  the 
cause  of  the  enuresis  seems  to  be  an  enlarged  rueatus.  An  incision 
is  then  made  in  the  sagittal  plane  on  either  side  of  the  urethra,  and  the 
edges  are  united  at  right  angles  to  the  incision.  The  patient  should 
be  kept  in  bed  for  two  or  three  weeks.  The  wound  is  smeared  with 
cold-cream,1  or,  better,  dusted  with  stearate  of  zinc.  The  patient  may 
then  urinate  herself. 

B.  Fecal  Fistuke. — A  fecal  fistula  is  one  leading  from  the  intes- 
tine to  the  genital  canal.  They  are  much  less  common  than  urinary 
fistulse. 

Pathological  Anatomy. — There  may  be  one  or  more  openings.  The 
fistulous  communication  may  take  place  between  the  rectum  and  the 
vulva — recto-vulvar  or  recto-labial  fistula  ;  the  rectum  and  the  vagina — 
recto-vaginal  fistula  ;  between  the  ileum  or  the  sigmoid  flexure  of  the 
colon  and  the  vagina  or  uterus — entero-vaginal,  ileo-vaginal,  and  ileo- 
uterine  fistula. 

The  size  differs  from  that  of  an  opening  so  fine  that  it  may  be  very 
difficult  to  discover  to  that  of  one  easily  admitting  a  finger.  Often 
the  aperture  is  larger  on  the  vaginal  side  than  on  the  intestinal.  The 
seat  varies  also  very  much.  A  fecal  fistula  may  be  situated  anywhere 
between  the  intestine  and  the  vagina,  but  it  is  most  commonly  found 
either  immediately  above  the  sphincter  ani  muscles  or  at  the  fornix. 
As  a  rule,  it  is  found  on  the  posterior  wall  of  the  genital  canal,  but  the 
entero-vaginal  variety  may  exceptionally  open  in  front  of  the  uterus. 
Sometimes  the  length  is  almost  nil,  the  rectal  and  vaginal  walls  com- 
ing in  contact  in  the  thin  septum  between  the  two.  In  other  cases, 
when  the  fistula  is  the  result  of  an  abscess,  the  inner  opening  may  be 
as  much  as  three  inches  and  a  half  up  the  rectum,  while  the  outer  is 
found  on  the  inside  of  the  labium  majus. 
1  D.  Tod  Gilliam  of  Columbus,  O.,  Amer.  Jour.  Obst.,  1896,  vol.  xxxiii.,  No.  2,  p.  177. 


DISEASES  OF  THE   VAGINA.  381 

Etiology. — The  causes  of  fecal  fistulae  are  in  many  respects  like  those 
determining  urinary  fistulse.  The  most  common  is  childbirth,  and  the 
fistula  may  either  be  due  to  pressure  between  the  fetal  head  and  some 
bony  prominence  in  the  pelvis  or  remain  as  the  result  of  imperfect 
spontaneous  healing  of  a  tear  through  the  perineal  body.  It  may  be 
brought  about  by  rupture  of  the  vagina  or  uterus,  an  intestinal  knuckle 
being  caught  in  the  rent  and  becoming  necrotic,  or  by  diphtheritic  and 
gangrenous  processes  due  to  puerperal  infection. 

Frequently  a  fistulous  opening  remains  just  above  the  artificially 
united  perineal  body  after  perineorrhaphy.  Rarely  hysterectomy  has 
led  to  the  formation  of  such  a  fistula  at  the  fornix. 

Occasionally  the  fistula  is  due  to  a  neglected  vaginal  pessary,  that 
gnaws  a  hole  into  the  rectum. 

Abscesses,  either  pelvic,  vulvar,  or  prerectal,  end  sometimes  with  the 
formation  of  a  fecal  fistula.  At  the  foruix  it  is  due  to  a  suppurating 
dermoid  cyst  or  extra-uterine  pregnancy ;  at  the  vulva  the  inflamma- 
tion begins  often  in  Bartholin's  glands. 

We  have  mentioned  above  that  direct  injury,  especially  violent 
coition,  may  cause  a  permanent  fistula  (p.  265)  and  that  the  solution 
of  continuity  may  be  due  to  ulcers — cancerous,  tubercular,  or  syphi- 
litic— perforating  the  partition  between  the  two  canals. 

In  syphilitic  patients  the  fistula  is  often  found  just  above  a  strict- 
ure of  the  rectum. 

Symptoms. — The  escape  of  flatus  and,  when  the  bowels  are  loose, 
thin  fecal  matter,  through  the  vagina  soon  attracts  the  patient's  atten- 
tion. The  irritating  contact  with  the  excrementitial  matter  causes 
catarrhal  vulvitis  and  vaginitis. 

Of  entero- vaginal  fistulae  there  are  two  varieties  with  very  different 
symptoms.  If  the  opening  is  small  (ileo-vaginal  fistula),  they  do  not 
differ  materially  from  any  other  fecal  fistula,  but  if  the  whole  circum- 
ference of  the  intestine  has  been  destroyed  and  the  edges  have  coa- 
lesced with  the  rent  in  the  vagina  (jpreternatural  anus),  all  the  feces 
find  their  exit  through  the  vagina.  If  the  affected  part,  as  usual,  is 
the  ileum,  undigested  food  mixed  with  bile  will  make  its  appearance 
at  the  fistula  about  two  hours  after  meals,  and  the  patient  \\  ill  loose 
flesh  and  finally  die  from  starvation.  Her  weakness  may  alr-o  cause 
ameuorrhea. 

Large  fecal  fistula?  can  be  felt,  small  ones  maybe  seen,  but  are  often 
hard  to  find  on  account  of  their  diminutive  size.  Probing  and  injec- 
tion with  colored  fluid  may  help  to  find  the  inner  opening. 

In  an  entero-vaginal  fistula,  a  whole  intestinal  knukle  having  been 
destroyed,  there  may  be  two  openings  with  a  so-called  spur  between 
them. 

Prognosis. — Fecal  fistulae  have  in  so  far  a  better  prognosis  than 
urinary  as  a  larger  number  of  them  heal  spontaneously,  but,  on  the 


382  DISEASES  OF  WOMEN. 

other  hand,  those  which  have  no  such  tendency,  are  harder  to  heal 
by  operation,  the  reason  of  which  is  doubtless  that  while  urine  is 
harmless  or  can  easily  be  given  an  exit,  the  intestine  is  always  full 
of  pathogenic  microbes,  which  it  is  difficult  or  impossible  to  keep 
away  from  the  wound.  Mechanical  difficulties  are  likewise  of  much 
importance  in  jeopardizing  closure  by  first  intention.  If  "\ve  induce 
constipation  large  fecal  masses  will  accumulate,  and  their  final  expul- 
sion may  tear  open  the  already  healed  fistula.  If,  on  the  other  hand, 
we  keep  the  bowels  loose,  the  contraction  of  the  perineal  muscles 
during  the  act  of  defecation  is  liable  to  cause  a  fistulous  tract  to 
remain  just  above  the  sphincter  ani  muscles. 

We  have  already  intimated  that  in  certain  forms  of  fecal  fistulae 
nutrition  becomes  insufficient. 

Treatment. — Preventive  Treatment. — Much  can  be  done  to  prevent 
the  formation  of  fecal  fistula?  by  having  their  etiology  in  mind. 
Thus  an  enema  of  soap-suds  should  invariably  be  given  in  every 
labor  case  before  the  head  enters  the  pelvic  cavity. 

The  pelvis  should  be  carefully  ^examined  before  labor  in  regard  to 
narrowness  or  projecting  points,  and  according  to  circumstances  re- 
course should  be  had  early  to  the  high-forceps  operation,  version, 
craniotomy,  or  even  Cesarian  section. 

Pessaries  should  always  be  kept  clean  with  daily  vaginal  injections, 
and  removed  at  least  once  every  two  months.  If  there  is  any  gnaw- 
ing, the  pessary  should  be  left  out  for  a  week  and  carbolized  injections 
used  until  all  abrasions  or  ulcers  are  healed. 

It  goes  without  saying  that  most  strenuous  efforts  should  be  made 
to  prevent  syphilitic  ulcers  from  forming  fistula?.  Perhaps  we  will 
soon  have  in  one  of  the  many  remedies  now  being  experimented  with 
a  means  of  checking  tuberculous  ulcers  in  their  destructive  progress. 

Even  at  the  height  of  sexual  passion  men  should  exercise  a  reas- 
onable control  over  themselves,  especially  if  nature  has  endowed  them 
with  an  unusual  development  of  the  part  concerned.  Pus  in  the 
pelvis  or  near  the  lower  end  of  the  rectum  should  be  given  an  exit 
by  timely  operative  interference. 

Curative  Treatment. — A  cure  may  be  obtained  by  cleanliness,  the 
elastic  ligature,  or  cutting  operations. 

A.  Since  many  small  fecal  fistula?  have  a  decided  tendency  to  close 
of  themselves,  this  happy  result  should  be  facilitated  by  scrupulous 
cleanliness,  especially  sitz-baths,  rectal  and  vaginal  injections,  and 
prevention  of  constipation,  combined  with  cauterization  (p.  365). 

B.  Ligature. — In  recto-labial  fistula,  which  we  have  seen  often 
extends  far  up  the  gut,  a  cutting  operation  would  be  liable  to  cause 
great  hemorrhage,  and  by  forming  a  cloaca  leave  the  patient  in  a 
worse  condition  than  she  was  before.     This  affection  is  treated  suc- 
cessfully by  changing  it  into  a  common  fistula  in  ano,  and  treating 


DISEASES  OF  THE   VAGINA. 


383 


that  with  the  elastic  ligature.1  The  usual  surgical  silver  probe, 
armed  with  an  elastic  ligature,  is  introduced  into  the  labial  orifice, 
pressed  down  to  the  perineum  just  outside  of  the  sphincter  ani,  where 
the  end  is  liberated  by  an  incision  and  the  probe  withdrawn.  A  more 
ductile  one  is  substituted,  and  passed  through  the  sinus  from  the  labial 
opening  to  the  rectal  opening,  having  the  eve  threaded  with  the  other 
end  of  the  ligature.  The  finger  introduced  into  the  rectum  recognizes 
the  probe,  which  is  then  curved  and  gently  drawn  through  the  rectum 
and  anus.  The  two  ends  of  the  ligature  are  tied,  shotted,  and  clamped 
(Fig.  228).  The  labial  orifice  is  left  to  itself  and  closes  in  a  few  days, 


FIG.  228. 


Barton-Taylor's  Operation  for  Recto-labial  Fistula:  A,  anal  end  of  ligature;  B,  labial  fistula  ; 
C,  incision  in  perineum.  The  fine  dotted  lines  mark  the  course  of  the  recto-labial  sinus ; 
the  heavy  dotted  lines  represent  the  ligature  where  it  is  imbedded  in  the  tissues. 

or  at  most  two  weeks,  for  just  as  soon  as  the  rectal  opening  is  united 
and  the  ulceration  or  sinus  gradually  healing  up,  there  can  no  longer 
pass  any  gas  or  fluid  feces  through  the  sinuous  tract  and  the  labial 
orifice. 

This  treatment  is  so  little  painful  that  the  patient  need  not  even 
be  kept  in  bed.  The  ligature  will  cut  through  in  from  three  to  eight 
days,  and  if  the  elastic  thread  ceases  its  pressure  the  remnant  of 

1  This  method  originated  with  Rhea  Barton  of  Philadelphia,  and  was  improved  by 
I.  E.  Taylor  of  this  city,  who,  on  November  18,  1885,  read  a  paper  on  Recto-labial 
and  Vulvar  Fistula  before  the  New  York  State  Medical  Association. 


384  DISEASES  OF  WOMEN. 

embraced  tissue  is  easily  severed  with  scissors  or  Paquelin's  cau- 
tery. 

C.  Catting  operations  may  be  performed  from  the  perineum,  the 
vagina,  or  the  rectum. 

I.  For  a  rectal  fistula  situated  low  down  three  different  suture- 
operations  recommend  themselves. 

1.  Emmet's  Method. — Split  the  perineal  body  with  scissors  in  the 
sagittal  plane  up  to  the  fistula,  cut  its  wall  away  and  unite  as  for 
ruptured  perineum  (p.  320). 

2.  Tait's  flap-splitting  method  with  circular  suture  (p.  369)  is  well 
adapted  to  these  small  openings. 

3.  Fritsch's    Flap-sliding  Method. — A  crescent  incision    is  made 
on  the  vaginal  wall  with  the  convexity  turned  down  and  just  touch- 
ing the  upper  border  of  the  fistula.     A  similar  incision  is  made 
between  the  ends  of  the  first  extending  half  an  inch  below  the  fistula. 
The  enclosed  crescent-shaped  part  of  mucous  membrane  is  dissected 
off.     Finally,  the  flap  above  the  fistula  is  drawn  down  so  as  to  cover 
this  denuded  surface  and  the  fistula,  and  fastened  all  around  with 
sutures1  to  the  mucous  membrane  or  the  skin. 

Whichever  method  be  used  it  is  best  first  to  paralyze  the  sphincter 
ani  muscle  by  overstretching  it. 

II.  Rectal  fistula  situated  higher  up  in  the  vagina  are,  as  a  rule, 
operated  on  from  the  vagina  in  one  of  three  ways :  Bureau  and  Vi- 
gnard's  treble  tier-suture,  Tait's  flap-splitting  operation,  or  Hegar's 
colpo-perineorrhaphia. 

1.  Bureau  and  Vignard  made  a  vertical  incision  in  the  median  line, 
extending  half  an  inch  above  and  below  the  fistula,  dissected  the  vagina 
from  the  rectum  to  a  distance  of  half  an  inch  from  the  fistula,  form- 
ing two  rectal  and  two  vaginal  flaps.  The  edges  of  the  rectum  were 
united  by  a  continuous  suture  of  chromicized  catgut,  avoiding  to  pene- 
trate into  the  interior  of  the  gut.  Relaxation  sutures  were  inserted 
at  the  angle  between  the  rectal  and  the  vaginal  flaps,  but  not  tied. 
Next,  the  edges  of  the  vaginal  flaps  were  brought  together  with  a 
continuous  suture  of  chromicized  catgut.  Finally,  the  relaxation 
sutures  were  tied.2 

These  fistulae  have  strongly  beveled  edges,  the  vaginal  opening  being 
much  larger  than  the  rectal. 

Sometimes  the  vaginal  edges  can  be  brought  together  after  making 
lateral  incisions  in  the  vagina,  but  cases  are  occasionally  met  with  in 
which  no  extent  of  division  of  tissue  on  the  vaginal  surface  will 
permit  of  the  edges  being  brought  together.  In  such  a  case  it 
is  necessary  to  split  the  edges  of  the  fistula  on  each  side  to  a  depth 
sufficient  to  permit  the  edges  of  the  rectal  wall  to  be  brought  to- 

1  H.  Fritsch,  CentralblaU  f.  Gyndk.,  1888,  vol.  xii.  p.  806. 

2  Bureau  and  Vignard,  Centralbl.  /.  Gyndk.,  1894,  vol.  xviii.  No.  40,  p.  991. 


DISEASES  OF  THE   VAGINA.  385 

gether  bslow,  leaving  the  vaginal  opening  to  be  filled  up  by  gran- 
ulation.1 

Denudation  in  fecal  fistulae  must  be  made  much  larger  than  in 
urinary.  In  the  lower  part  of  the  vagina  the  edges  are,  as  a  rule, 
united  from  side  to  side.  In  the  upper,  when  there  is  much  loss  of 
substance,  the  edges  must  sometimes  be  brought  together  in  a  trans- 
verse line. 

2.  Tail's  flap-splitting  with  interrupted  suture  (p.  370)  may  be 
available. 

3.  German  authors  recommend  a  denudation  and  adaptation  from 
side  to  side  as  in  Hegar's  operation  for  incomplete  rupture  of  the  peri- 
neum (p.  311). 

Operation  from  the  Rectum. — In  exceptional  cases  it  may  be  impos- 
sible to  bring  the  rectal  fistula  into  view  on  account  of  a  cicatricial 
band  at  the  outlet  of  the  vagina.  As  this  band  works  as  a  substitute 
for  the  lost  sphincter  urethrse  by  keeping  the  walls  of  the  urethra  in 
contact  (compare  p.  379)  it  should  not  be  divided.  Under  such  cir- 
cumstances the  operation  is  performed  from  the  rectal  side.2 

The  intestine  should  not  only  be  cleaned  out  by  high  enemas  of 
water  and  irrigated  with  an  antiseptic  solution  during  the  operation 
(p.  222),  but  it  may  even  be  well  to  try  to  combat  the  germs  in  the 
upper  part  of  the  intestine  by  the  internal  administration  of  naphtha- 
line (gr.  ij  to  viij  pro  dosi,  up  to  gr.  Ixxx  in  twenty-four  hours)  or 
salicylate  of  bismuth  (gr.  x  every  two  hours).  The  sutures  are  put  in 
near  the  edge  on  the  rectal  side,  but  should  go  out  a  quarter  of  an 
inch  from  the  edge  on  the  vaginal  side. 

Entero-vaginal  Fistulas? — -If  the  fistula  is  only  lateral  it  may  be 
closed  by  denudation  and  suture  like  another  fecal  fistula.  In  a  case 
of  vaginal  anus  it  must  be  ascertained  if  the  lower  part  of  the  bowel 
is  pervious,  as  it  is  evident  that  no  closure  must  be  attempted  unless 
an  exit  can  be  given  to  the  fecal  matter. 

Different  operations  have  been  performed  or  proposed  for  the  relief 
of  this  kind  of  fistula. 

1.  If  there  is  a  double  opening  the  spur  between  the  two  may  be 
cut  by  introducing  Dupuytren's  enterotome,  or  another  strong  pair  of 
forceps,  to  the  depth  of  one  and  a  quarter  inches,  and  the  edges  of  the 
fistula  denuded  and  united  by  sutures. 

2.  Laparotomy  may  be  performed,  the  intestine  cut  loose  from  the 
vagina  or  uterus,  and  the  ends  united  by  enterorrhaphy. 

If  the  lower  end  is  closed  or  too  narrow  an  anastomosis  may  be 
effected  between  the  upper  end  and  the  large  intestine. 

1  T.  A.  Emmet's  Gyruxology,  p.  662. 
a  Emmet,  /.  c.,  p.  666. 

3  Thirty-nine  cases  have  been  collected  by  H.  L.  Petit,  Annales  de  Gynecologic, 
vols.  xviii.,  xix.,  xx.,  1882-83. 
25 


386  DISEASES  OF  WOMEN. 

3.  It  has  also  been  proposed  to  loosen  the  intestine  and  insert  it  in 
the  rectum  from  the  vagina. 

4.  After  having  made  an  artificial  recto  vaginal  fistula,  colpocleisis 
may  be  performed  under  it. 

General  Remarks  about  the  Operation  for  Fecal  Fistulce. — In  ope- 
rations from  the  vagina  or  the  perineum  Simon's  position  (p.  368) 
should  be  used.  It  is  often  a  help  to  introduce  a  small  Sims  specu- 
lum under  the  symphysis  pubis  and  lateral  retractors  on  the  sides  of 
the  vagina.  In  operations  from  the  rectum  Sims's  position  or  the 
genupectoral  should  be  used. 

Silver-wire  sutures  are  preferable.  If  used  in  the  rectum  they 
should  be  turned  down  toward  the  anus  sa  as  not  to  offer  any  resist- 
ance to  the  exit  of  the  feces.  They  may  be  left  in  two  weeks  while 
silk  must  be  removed  at  the  end  of  the  first  week.  The  bowels 
should  of  course  be  emptied  before  operating.  After  the  operation 
they  are  best  let  alone  for  three  days.  After  that  daily  loose  pas- 
sages should  be  secured  by  means  of  medicines  (pp.  2,25  and  322). 
The  patient  may  urinate  herself. 


PART  IV. 

DISEASES  OF  THE  UTERUS. 


CHAPTER  I. 

MA  INFORMATIONS. 

MALFORMATIONS  of  the  uterus  may  be  due  to  excessive  develop- 
ment and  precocity,  to  arrest  of  development  or  to  irregular  development. 
Those  due  to  arrest  of  development  correspond  again  either  to  the  first 
or  the  second  half  of  fetal  life.  By  bearing  in  mind  the  history  of  the 
normal  development  of  the  uterus  (p.  30)  the  many  abnormal  forms 
of  uteri  due  to  arrest  of  this  development  are  easily  understood. 
Since  the  uterus  is  formed  by  the  fusion  and  further  development  of 
the  middle  part  of  the  Miillerian  ducts  we  have  no  difficulty  in 
realizing  that  that  part  may  originally  have  been  absent  or  may  have 
been  destroyed,  or  that  the  originally  solid  filaments  may  have  failed 
to  become  tunneled,  or  that  the  muscular  tissue  which  should  be  formed 
around  them  may  do  so  in  an  imperfect  way,  or  that  fusion  does  not 
take  place  between  the  two  tubes,  or  does  so  only  partially,  or  that 
only  one  of  the  tubes  undergoes  its  regular  development,  while  the 
other  stays  rudimentary  or  is  absent.1 

A.  Excessive  Development  and  Precocity. — Sometimes  the  uterus  in 
the  new-born  child  has  the  size  and  shape  of  that  of  a  girl  at  puberty 
(p.  33). 

As  to  menstruation  during  early  childhood  we  refer  to  what  has 
been  said  on  p.  244. 

B.  Arrest  of  Development  during  the  First  Half  of  Intra-uterine 
Life — 1.  Absence  of  Uterus. — Complete  absence  of  every  vestige  of 
a  uterus  is  a  rare  occurrence.     It  may,  however,  be  found  in  other- 
wise well  built  women,  but  it  is  mostly  combined  with  other  defects 
in  the  genitals  or  in  other  parts  of  the  body. 

Diagnosis. — The  total  absence  of  the  uterus  cannot  be  diagnosti- 
cated in  the  living  woman,  and  even  in  post-mortem  examinations 
the  pathologist  must  be  on  his  guard. 

1  Those  who  want  more  information  about  malformations  than  that  warranted 
by  the  limits  of  this  book  are  referred  to  my  article  on  the  subject  in  the  Amer., 
JSyst.  of  GynecoL,  vol.  i.,  pp.  238-257. 

3S7 


388  DISEASES  OF  WOMEN. 

2.  Rudimentary  Uterus. — In  some  extremely  rare  cases  the  uterus 
has  only  been  represented  by  a  solid  fibrous  or  muscular  mass.     In 
others  it  consists  of  a  membranous  vesicle. 

In  none  of  the  cases  of  rudimentary  uterus  authenticated  by  autopsy 
was  there  any  menstrual  flow,  but  often  molimina. 

3.  Uterus  Duplex  Separatus,  or  Uterus  Didelphys  (Fig.  229). — This 
variety  is  produced  when  the  two  Miillerian  ducts  do  not  even  come 

FIG.  229. 


Uterus  Didelphys  (Ollivier) :  a,  right  body ;  b,  left  body ;  c,  right  ovary ;  d,  right  round  liga- 
ment ;  e,  left  round  ligament ;  /,  left  tube ;  g,  left  cervix ;  h,  right  cervix ;  i,  right  vagina ; 
j,  left  vagina ;  k,  partition  between  the  two  vaginae ;  I,  right  tube. 

in  contact  with  one  another  in  that  part  of  their  course  in  which  they 
usually  melt  together  forming  the  uterus.  Consequently  there  are 
two  entirely  separate  uteri,  but  each  of  them  represents  only  one-half 
of  the  total  organ.  Each  half  has  at  its  upper  end  one  Fallopian 
tube  and  one  round  ligament.  At  the  lower  end  the  double  cervix 
opens  into  a  single  or  double  vagina,  or  this  organ  may  be  more  or 
less  defective. 

The  uterus  didelphys  is  mostly  found  in  still-born  children,  but 
occurs  also  in  adults.1  Pregnancy  and  childbirth  may  be  entirely 
normal. 

It  is  hardly  possible  to  diagnosticate  the  uterus  didelphys  from 
a  uterus  bicornis  in  the  living  woman,  through  the  closed  abdominal 
wall. 

1  I  have  seen  one  in  performing  laparotomy  on  a  girl  twenty  years  old.  In  this 
case  the  vagina  was  normal. 


DISEASES  OF  THE   UTERUS.  389 

4.  Uterus   Unicornis  (Fig.  230). — The  one-horned  uterus  is  due 
to  the  development  of  one  of  Miiller's  ducts,  while  the  other  is 


FIG.  230. 


Uterus  Unicornis  with  Rudimentary  Right  Horn  (Schroeder) :  LH,  left  horn ;  Lo,  left  ovary ; 
LT,  left  tube ;  LLr,  left  round  ligament ;  RH,  right  horn ;  Ro,  right  ovary ;  RT,  right  tube ; 
Riff,  right  round  ligament. 

absent  or  stays  rudimentary.  It  is  always  very  long,  forms  a  curve 
with  the  concavity  turned  outward,  and  ends  in  a  point  without 
fundus. 

The  diagnosis  may  sometimes  be  made  by  bimanual  and  rectal 
examination,  by  the  shape  and  position.  Pregnancy  and  childbirth 
may  take  their  normal  course. 

But  attached  to  the  point  where  the  cervix  merges  into  the  body  of 
the  unicorn  uterus  is  sometimes  found  a  rudimentary  horn.  If  preg- 
nancy takes  place  in  that,  the  condition  is  a  very  grave  one,  the  rudi- 
mentary horn  being  incapable  of  producing  the  necessary  muscular 
tissue  to  form  a  sac  for  the  growing  fetus.  The  condition  is,  then, 
practically  the  same  as  in  tubal  pregnancy,  from  which  it  cannot  be 
distinguished  clinically.  Even  anatomically  the  examiner  may  be 
led  into  error,  if  he  does  not  bear  in  mind  that  the  round  ligament 
forms  the  line  of  demarkation  between  the  uterus  and  the  tube 
(p.  58).  A  tube,  be  it  ever  so  narmw,  if  situated  inside  of  the 
round  ligament,  is  a  horn  of  the  uterus,  while  the  Fallopian  tube 
starts  from  the  same  point  as  the  round  ligament  aud  extends  out- 
ward. 

The  treatment  is  also  like  that  for  tubal  pregnancy — namely,  a 
strong  electric  current  for  the  purpose  of  killing  the  fetus,  or  removal 
by  means  of  laparotomy. 

In  very  rare  cases  menstrual  blood  has  accumulated  in  the  rudi- 
mentary horn,  forming  a  tumor  (hematometra).  In  such  a  case  lapa- 
rotomy, ligature  of  the  pedicle,  and  removal  constitute  the  only 
means  of  relief.  (Compare  Salpingo-oophorectomy  under  Diseases 
of  the  Tubes.) 


390  DISEASES  OF  WOMEN. 

5.  Uterus  Bicornis  (Fig.  231). — When  the  Miillerian  ducts  remain 
more  or  less  separated  from  one  another  in  that  part  which  forms  the 
uterus,  this  organ  appears  with  two  more  or  less  distinct  horns  at  its 
upper  end.  There  may  be  a  complete  partition  going  all  the  way 
down  to  the  external  os,  so  that  there  is  a  double  cervix,  or  the  cervix 
may  be  single,  or  the  partition  may  be  absorbed  more  or  less  high  up 
between  the  two  horns,  until  it  is  only  represented  by  a  ridge  at  the 

FIG.  231. 


ag* 

Uterus  Bicornis  (Hunkemiiller) :  ur,  urethra  cut  off;  iu,  meatus  urinarius;  vag  and  vug*, 
entrance  to  the  double  vagina,  the  anterior  wall  of  which  has  been  removed,  showing 
the  two  vaginal  portions  of  the  two-horned  uterus. 

fundus  inside,  while  the  Jjorns  are  only  separated  by  a  corresponding 
slight  depression  on  the  outside,  so  that  both  the  external  contour  and 
the  cavity  have  somewhat  the  shape  of  a  heart  on  playing-cards. 

6.  Uterus  septus,  or  bilocularis,  is  a  uterus  with  a  complete  partition 
between  the  two  halves,  but  with  the  normal  shape  of  a  uterus  out- 
side, a  kind  that  is  of  much  rarer  occurrence  than  the  corresponding 
bicoruute  variety. 

If  part  of  the  septum  has  been  absorbed,  the  uterus  is  called  sub- 
septus — i.  e.  partially  partitioned. 

In  all  forms  of  double  uterus,  be  it  horned  or  not,  the  vagina  may 
be  single  or  double  (p.  332).  The  menstrual  flow  may  come  from 
one  or  both  halves,  and  if  from  both,  it  may  either  come  fr6m  both 
sides  at  the  same  time  or  alternately  from  each  half. 

Pregnancy  may  take  place  in  either  half  or  in  both  at  once.  Even 
if  it  is  confined  to  one  side,  the  other,  as  a  rule,  partakes  in  the  pro- 


DISEASES   OF  THE    UTERUS.  391 

cess,  forming  a  decidua,  and  producing  muscular  hyperplasia  and 
hypertrophy. 

The  presence  of  a  double  uterus  serves  to  explain  many  cases  of 
superfetation,  an  occurrence  that  is  impossible  in  a  single  uterus  after 
the  third  month  of  gestation. 

Childbirth  takes  in  most  cases  a  normal  course,  but  complications 
are  comparatively  much  more  frequent  than  with  a  normal  uterus. 

Diagnosis. — The  presence  of  a  two-horned  uterus  may  sometimes 
be  felt  by  bimanual  examination  or  from  the  rectum. 

The  condition  of  the  septum  in  a  double  uterus  is  ascertained  by 
simultaneous  use  of  two  sounds,  one  in  either  half  of  the  uterus.  If 
there  is  a  communication  between  the  two,  the  sounds  may  be  brought 
in  direct  contact. 

7.  Atresia  Uteri. — Just  as  we  have  seen  above  (pp.  326  and  328) 
that  the  hymen  or  the  vagina  may  be  closed,  the  uterine  canal  itself, 
although  more  rarely,  may  be  the  site  of  atresia.  The  mucous  mem- 
brane of  the  vagina  may  cover  the  whole  vaginal  portion  without 
forming  any  external  os,  or  the  cervix  forms  one  uninterrupted  mus- 
cular mass  without  bore.  In  such  cases  the  vaginal  portion  may  be 
well  developed  or  totally  absent.  In  a  bicornate  uterus  one  horn 
may  be  closed. 

In  regard  to  symptoms,  prognosis,  diagnosis,  and  treatment,  we 
refer  to  what  has  been  said  above  in  treating  of  atresia  of  the  hymen 
and  the  vagina  (pp.  327—330).  Wherever  the  genital  canal  is 
closed  the  symptoms  due  to  retention,  such  as  amenorrhea,  pain, 
menstrual  molimina,  and  the  formation  of  a  tumor,  are  the  same. 
Here  wre  will  only  mention  a  few  special  features  belonging  to 
atresia  when  it  is  situated  in  the  uterus.  The  vagina  can  be  ex- 
plored to  its  full  extent  with  the  finger  and  the  speculum.  Above 
it  the  uterus  forms  a  round  elastic  tumor,  iu  the  differentiation  of 
which  the  examiner  must  especially  think  of  pregnancy,  fibroma, 
and  hematocele. 

In  a  case  of  pregnancy  the  patient  will,  as  a  rule,  have  menstruated 
before  being  impregnated,  and  more  or  less  of  the  well-known  signs 
of  pregnancy  will  be  present.  A  fibroid  forms  a  hard  nodular  tumor, 
and  causes  often  menorrhagia.  Hematocele  appears  suddenly  and 
forms  a  broader  mass,  which  pushes  the  uterus  forward. 

If  the  uterus  is  double,  the  atresia  is  found  much  more  frequently 
on  the  right  side.  As  a  rule,  the  tumor  will  begin  to  form  at  the 
time  of  puberty  and  increase  with  every  monthly  period,  as  in  atresia 
of  the  single  uterus,  but  sometimes  the  development  is  slow  and 
irregular.  Blood  may  accumulate  in  the  corresponding  tube,  which 
gives  way  before  the  stronger  uterine  wall  is  ruptured.  The  closed 
horn  may  become  adherent  to  the  anterior  abdominal  wall,  and  rup- 
ture take  place  through  it.  The  hematometra  may  also  rupture  into 


392  DISEASES  OF  WOMEN. 

the  stomach  or  the  intestine,  which  leads  to  septicemia  and  death. 
The  least  dangerous  rupture  is  that  through  the  partition  into  the 
pervious  part  of  the  uterus,  in  which  way  a  permanent  cure  may  be 
effected ;  but  in  other  cases  the  opening  closes  again  and  a  new  accu- 
mulation takes  place,  which  in  consequence  of  the  entrance  of  pyo- 
genic  bacilli  becomes  purulent  (pyomt&ra).  This  abscess  may  again 
open  into  the  normal  half  of  the  uterus,  from  which  the  pus  then  flows 
out,  or  it  may  burst  into  the  peritoneal  cavity,  causing  septic  perito- 
nitis. 

Exceptionally,  the  contents  of  the  closed  horn  are  only  mucus 
(hydrometrd).  If  a  purulent  collection  becomes  decomposed  gases 
are  formed  in  the  cavity  of  the  uterus,  a  condition  called  physo- 
metra. 

Treatment. — If  the  uterus  is  single,  a  puncture  should  be  made 
through  the  cervix  with  a  trocar  and  enlarged  with  a  bistoury  or  a 
metrotome.  After  evacuation  an  iodoform-gauze  drain  should  be  left 
in  the  uterus,  and  after  its  removal  a  perforated  intra-uterine  glass 
stem  should  be  inserted  in  order  to  keep  the  cervix  open.  Later, 
curetting  of  the  endometrium  and  packing  with  iodoform  gauze  will 
combat  endometritis  and  help  to  bring  the  distended  and,  as  a  rule, 
hypertrophied  uterus  back  to  a  normal  condition. 

If  the  accumulation  is  found  in  one  half  of  a  double  uterus  it  is 
still  an  advantage,  if  possible,  to  enter  through  the  cervix,  but  often 
there  is  no  choice  and  the  tumor  must  be  punctured  at  its  lowest  point 
in  the  vagina.  Puncture  alone,  even  repeated,  rarely  effects  a  cure, 
and  it  should,  therefore,  be  followed  by  an  incision,  or  even  an  exci- 
sion, of  a  portion  of  the  wall,  so  as  to  insure  permanent  communica- 
tion with  the  open  half  of  the  genital  canal.  When  the  closed  half 
has  been  punctured  and  evacuated  it  may  be  possible  to  dilate  the 
open  half  by  Vulliet's  method  (p.  156)  and  remove  a  part  of  the 
partition  between  the  two  halves  of  the  uterus. 

If  the  swelling  cannot  be  reached  from  the  vagina,  laparotomy 
should  be  performed  and  the  affected  horn  or  the  whole  uterus  re- 
moved as  for  a  fibroid. 

If  blood  has  collected  in  the  Fallopian  tube,  and  there  is  no  com- 
munication with  the  uterine  cavity,  it  is  best  to  let  it  alone,  as  it  may 
perhaps  be  reabsorbed.  If  the  tubal  sac  grows,  it  may  be  punctured 
from  the  uterus  or  the  vagina,  and  in  the  latter  place  treated  with 
injection  and  drainage.  Laparotomy  and  removal  of  the  distended 
tube  may  be  tried,  but  it  is  liable  to  prove  difficult  or  impossible  on 
account  of  adhesions. 

C.  Arrest  of  Development  during  the  Second  Half  of  Intra-uterine 
Life. — 1.  Fetal  and  Infantile  Uterus. — Some  adult  women  have  a 
womb  that  in  size  and  configuration  corresponds  to  that  of  a  fetus 
toward  the  end  of  pregnancy  or  that  of  a  young  child.  Sometimes 


DISEASES  OF  THE   UTERUS.  393 

it  is  only  an  inch  and  a  half  deep ;  in  other  cases  it  has  the  size  of  a 
virgin  uterus,  but  is  characterized  by  the  preponderance  of  the  neck 
over  the  body  and  the  thinness  of  the  walls  of  the  latter.  The  folds 
of  the  mucous  membrane  may  either  be  confined  to  the  cervix  or 
extend  more  or  less  up  into  the  cavity  of  the  body. 

The  fetal  uterus  may  at  the  same  time  be  two-horned  (p.  390),  as 
the  result  of  a  double  arrest  of  development.  The  other  organs  may 
be  normal,  but  often  the  condition  is  combined  with  other  abnormali- 
ties, especially  of  the  ovaries. 

2.  The  pubescent,  or  congenitally  atrophic,  uterus  is  one  that  is  char- 
acterized by  its  small  weight,  which  does  not  exceed  one  ounce,  but 
the  cervix  and  body  have  about  the  same  length. 

Etiology, — Besides  simple  arrest  of  development  from  unknown 
causes,  exudative  perimetric  inflammation,  chlorosis,  and  tuberculosis 
may  cause  the  deficient  development  of  the  uterus. 

Symptoms. — Menstruation  is,  as  a  rule,  absent  or  scanty.  Often 
the  patient  suffers  from  dysnieuorrhea,  and  sometimes  vicarious  men- 
struation (p.  241)  takes  place.  All  sorts  of  disorders  in  organs  out- 
side the  pelvis  (pp.  247-249)  may  occur  with,  or  instead  of,  the  men- 
strual flow. 

Sexual  appetite  may  be  unimpaired,  but  as  a  rule  women  with  too 
small  a  uterus  are  sterile,  or  if  they  conceive  they  are  apt  to  abort. 

Prognosis. — The  prognosis,  especially  in  regard  to  sterility,  should 
be  guarded,  but  a  late  development  of  the  uterus,  leading  to  concep- 
tion and  childbirth,  has  been  observed. 

Diagnosis. — The  condition  can,  as  a  rule,  be  made  out  by  palpa- 
tion, especially  through  the  rectum,  and  the  use  of  the  sound. 

Treatment. — If  tuberculosis  or  chlorosis  be  present,  the  practitioner 
should  carefully  abstain  from  any  local  treatment  that  is  likely  to 
bring  on  the  courses:  the  patient  being  anemic,  her  condition  will 
only  become  worse  by  losing  blood.  In  such  cases  a  general  tonic 
treatment  is  indicated  (pp.  224-226). 

If  the  patient  is  in  good  health,  and  sterility  the  chief  complaint, 
galvanic  treatment  with  the  negative  pole  in  the  uterus  and  faradiza- 
tion have  often  good  effect. 

If  she  suffers  from  dysmenorrhea,  vicarious  menstruation,  and  dys- 
menorrheic  disorders  outside  of  the  pelvis,  she  should  be  treated 
according  to  the  rules  laid  down  above  (pp.  241,  243,  244,  249)  in 
discussing  those  conditions,  especially  with  tonics,  a  strengthening 
regimen,  sedatives,  electricity,  and  the  uterine  sound. 

3.  Uterus  Parvicollis  and  Acollis. — Sometimes  the  body  of  the 
uterus  is  well  developed,  but  the  cervix  is  too  small,  or  the  vaginal 
portion  is  absent.     In  other  cases  the  body  is  likewise  too  small,  but 
the  hypoplasia  is  most  pronounced  in  the  neck.     These  deformities 
have  more  pathological  than  clinical  interest. 


394  DISEASES  OF  WOMEN. 

4.  Anteflexion  of  the  uterus  is  often  congenital,  and  simply  a  con- 
tinuation of  the  shape  of  the  uterus  found  in  the  fetus  and  young 
children.  This  condition  will  be  considered  together  with  other  dis- 
placements of  the  uterus. 

D.  Irregular  Development. — 1.  Obliquity. — The  uterus  may  be  con- 
genitally  bent  to  one  side  (later  oflexion),  the  two  Miilleriau  ducts  that 
formed  it  not  having  kept  pace  with  one  another.  Or  a  similar  con- 
dition may  be  produced  by  fetal  peritonitis  and  cicatricial  shrinkage 
of  one  of  the  broad  ligaments. 

A  normally  shaped  uterus  may  be  tilted  to  one  side  (lateroversioii), 
especially  when  there  is  a  beginning  ovarian  hernia. 

2.  Malposition. — In  consequence  of  an  uneven  development  of  the 
broad  ligaments  the  uterus  may  be  placed  not  in,  but  to  one  side  of, 
the  median  line  of  the  pelvis,  later oposition. 

A  similar  irregular  development  of  the  parts  situated  in  front  of 
and  behind  the  uterus  leads  to  anteposition,  when  the  uterus  is  situ- 
ated too  near  the  symphysis,  or  retr oposition,  when  it  is  drawn  too 
near  to  the  sacrum. 

3.  Hernia    Uteri. — The   uterus   has   been  found  in  a  congenital 
inguinal  hernia.     In  such    cases  the   ovary  descends  first  through 
the  inguinal  canal,  just  as  the  testicle  descends,  or  rather  is  drawn, 
into  the  scrotum.     The  uterus  has  also  been  found  in  a  crural  her- 
nia.    Such  hernise  are  exceedingly  rare.     The  patient  may  become 
impregnated  and  the  fetus  develop  in  the  hernia,  whence  it  has  to 
be   removed    by  Cesarian   section.     If  the   condition   comes  under 
observation  earlier  and  gives  trouble,  hysterectomy  might  be  per- 
formed. 

4.  Elongated  Cervix  and  Stenosis  of  the  Cervical  Canal  are  often 
found  as  a  congenital  irregularity,  but  will  be  treated  of  together 
with  the  same  conditions  when  acquired  later  in  life,  in  a  subsequent 
chapter.     (See  Hypertrophy  of  Uterus). 


CHAPTER  II. 
INJURIES. 

A.  Injuries  of  the  Body. — On  account  of  its  position  in  the  depth 
of  the  pelvic  cavity  the  unimpregnated  uterus  is  little  exposed  to 
injuries,  but  when  during  pregnancy  it  rises  up  from  the  pelvis  and 
rests  gainst  the  abdominal  wall  it  is  so  much  more  frequently  the  seat 
of  traumatic  lesions,  such  as  goring  with  a  bull's  horn,  kicks  with 
heavy  boots,  stab-wounds,  or  shot-wounds.1 

1  An  interesting  case  of  the  last  kind  was  reported  by  Dr.  George  A.  B.  Hays, 
of  Plaqueminos,  La.,  in  Gaillard's  Med.  Jour.,  Nov.,  1879,  p.  402,  et.  seq. 


DISEASES  OF  THE   UTERUS.  395 

While  in  such  cases  injury  is  inflicted  through  the  abdominal  wall, 
the  pregnant  uterus  is  exposed  through  the  vagina  to  the  manipula- 
tions of  abortionists.  In  reading  the  evidence  in  suits  for  malpractice 
one  is  at  a  loss  to  decide  whether  the  rascality,  the  recklessness,  or 
the  ignorance  of  these  people  is  the  greatest.  In  their  eagerness  to 
destroy  the  fetus  they  sometimes  make  a  wound  in  the  uterus  large 
enough  to  admit  the  thumb  and  allow  the  intestines  to  enter  the  uterus.1 

But  even  in  legitimate  gynecological  operations  the  uterus  is  occa- 
sionally wounded.  Some  uteri  are  so  soft  that  they  are  easily  pene- 
trated by  the  sound  or  the  dull-wire  curette.  Sometimes  in  perform- 
ing laparotomy  the  gravid  uterus  has  been  mistaken  for  an  ovarian 
cyst  and  a  trocar  thrust  into  it.2 

In  regard  to  rupture  of  the  gravid  uterus  during  labor  the  reader 
is  referred  to  works  on  obstetrics. 

Prognosis. — With  the  exception  of  the  simple  perforation  of  the 
uterus  with  sound  or  curette,  which  if  the  instruments  are  clean,  and 
injection  of  irritating  fluid  is  omitted,  has  no  bad  consequence,  most 
of  these  injuries  are  very  serious,  lead,  as  a  rule,  to  miscarriage,  and 
are  sometimes  accompanied  by  hemorrhage  or  peritonitis  and  death. 
Still,  if  the  ovum  has  not  been  opened,  and  occasionally  even  after 
evacuation  of  the  liquor  amnii,  pregnancy  may  take  its  course  to  term. 
In  those  cases  in  which  a  pregnant  uterus  is  ripped  open  by  the  horn 
of  cattle  the  prognosis  is  better  than  one  would  expect  from  the  vio- 
lence of  the  injury,  which  can  only  be  accounted  for  by  the  excellent 
health  of  the  persons  wounded  in  this  way.3 

Treatment. — In  cases  of  wounds  through  the  abdominal  wall  rest, 
opium,  and  antiseptic  dressing  of  the  wound  probably  offer  the  best 
chances,  but  if  there  are  signs  of  internal  hemorrhage,  laparotomy 
should  be  performed,  and  the  bleeding  vessel  tied.  If  possible  the 
fetal  sac  should  not  be  disturbed. 

When  the  uterus  has  been  wounded  from  within,  as  a  rule,  no  trcat- 
'ment  but  rest  is  required.  If  there  is  prolapse  of  the  intestine,  lap- 
arotomy should  be  performed  in  order  to  withdraw  the  intestine  and 
close  the  uterus.  If  the  intestine  is  gangrenous,  part  of  it  may  be 
resected;  or  it  may  be  left  undisturbed,  when  an  intestine-uterine 
fistula  will  form,  a  condition  that  not  only  is  compatible  with  life, 
but  may  be  cured  by  nature's  sole  efforts. 

If  the  gravid  uterus  is  punctured  in  laparotomy  and  the  ovum 
opened,  Cesarean  section  should  be  performed,  but  if  the  trocar  does 

1  Cases  of  this  kind  were  mentioned  by  Thomas,  Munde,  and  Nfeggerath  in  the 
N.  Y.  Obst.  Society,  April  5,  1881,  Amer.  Jour.  Obst.,  1882,  Supplement,  p.  5. 

2  An  interesting  paper  on  this  subject  by  Dr.  C.  C.  Lee  is  found  in  Tranx.  Avici: 
Gyn.  Soc.,  1883,  vol.  viii.,  p.  154. 

3  Out  of  14  cases  9  recovered,  R.  P.  Harrison,  Amer.  Ned.  Jour.  £«'.,  Oct.,  1891, 
vol.  cii.,  p.  376,   and  Monograph :    Abdominal  and    Uterine   Tolerance  in  Prcqnnnt 
Women,  Philadelphia,  1892,  pp.  12-15. 


396  DISEASES  OF   WOMEN. 

not  enter  the  ovum  the  opening  in  the  uterus  may  be  closed  with  silk 
sutures  and  pregnancy  allowed  to  take  its  normal  course. 

B.  Laceration  of  the  Cervix. — By  far  the  most  common  injury  to 
the  uterus  is  that  sustained  by  the  cervix  during  childbirth,  when  it 
is  ruptured,  or  lacerated,  that  is  to  say,  torn. 

Pathological  Anatomy. — These  tears  occupy  always  the  direction 
of  the  radius  of  the  os.  They  may  be  complete — that  is  to  say,  go 
through  the  whole  thickness  of  the  cervix — or  incomplete,  Avhen  the 
tear  in  the  cervical  canal  does  not  reach  the  mucous  membrane  of  the 
vagina.  There  may  be  one,  two,  or  many  tears.  The  one  most  com- 
monly observed  is  the  bilateral,  and  next  to  that  the  unilatei-al, 
which  is  more  frequent  on  the  left  than  on  the  right  side,  doubtless 
on  account  of  the  greater  frequency  of  the  left  occipito-anterior  posi- 
tion of  the  fetus.  The  laceration  may  also  be  stellate  ;  that  is,  when 
there  are  at  least  three  tears  forming  a  starlike  figure.  It  is  funnel- 
shaped  when  there  are  several  incomplete  tears,  which  result  in  a 
patulous  os.  Sometimes  it  becomes  crescentic  through  the  bulging 
of  a  hyperplastic  anterior  lip.  In  other  cases  the  tear  is  found  in 
the  posterior  or  anterior  lip  alone.1 

The  tear  extends  often  more  or  less  beyond  the  vaginal  junction  and 
enters  the  parametrium  or  the  connective  tissue  behind  the  uterus, 
or  extends  into  the  bladder.  Often  it  gives  rise  to  cellulitis  in  these 
parts,  which  through  cicatricial  contraction  may  lead  to  displacements 
of  the  uterus.  If  the  tear  implicates  the  bladder,  it  may  leave  a 
vesico-vaginal  or  vesico-uterine  fistula  (pp.  363  and  377). 

Commonly  the  laceration  of  the  cervix  is  followed  by  chronic 
inflammation  of  the  neck  and  the  body  of  the  uterus.  In  conse- 
quence of  hyperplasia  and  hypertrophy  of  the  glands  of  the  cervical 
mucous  membrane,  infiltration  with  round  cells  in  the  interstitial 
connective  tissue,  which  later  are  replaced  by  new  fibers,  and  abnormal 
afflux  of  blood,  the  mucous  membrane  becomes  swollen,  red,  and  rolls 
out  (ectropium),  and  the  lips  become  separated,  a  condition  which  is 
increased  by  pressure  against  the  posterior  wall  of  the  vagina.  Often 
the  outlet  of  the  glands  becomes  closed,  and  then  small  round  cysts 
are  formed,  which  are  filled  with  a  fluid  like  the  raw  white  of  an  egg, 
feel  like  shot,  and  appear  as  translucent  yellowish  spots. 

The  connective  tissue  in  the  muscular  layer  of  the  cervix  becomes 
also  hyperplastic,  so  that  the  cervix  becomes  larger  and  harder  than 
normal.  The  lips,  especially  the  anterior,  become  elongated. 

The  body  of  the  womb  does  not  undergo  the  normal  involution,  but 
stays  large  and  heavy,  and  becomes  the  seat  of  a  chronic  inflammation. 

Tears  may  heal  completely  by  first  or  second  intention,  but  in  the 

1  Most  of  these  varieties  are  beautifully  represented  on  colored  plates  accompany- 
ing an  excellent  article  on  the  Indications  for  Hystero-trachdorrhaphy  by  P.  F.  Munde 
in  the  Amer.  Jour.  Obst.,  1879,  vol.  xii.  p.  134. 


DISEASES  OF  THE   UTERUS.  397 

latter  case  the  proce&s  is  often  incomplete. :  a  cicatricial  plug  of  hard 
connective  tissue  is  formed  in  the  angle  between  the  lips,  and  the 
lower  part  of  these  does  not  unite. 

On  the  other  hand,  the  tear  may  heal  from  the  tip  of  the  cervical 
portion  to  near  its  base,  leaving  a  small  opening,  which  constitutes  a 
utero-vaginal  fistula  without  importance.  A  similar  opening  may 
remain  after  artificial  closure. 

Symptoms. — In  the  moment  the  laceration  takes  place,  it  may  be 
accompanied  by  arterial  hemorrhage.  An  old  laceration  gives  also 
frequently  rise  to  abnormal  loss  of  blood,  be  it  menorrhagia  or  met- 
rorrhagia  (pp.  245  and  247)  from  the  cervix  or  from  the  endomet- 
rium  of  the  body.  In  the  interval,  the  patient  suffers  from  leucor- 
rhea.  This  double  drain  produces  soon  anemia.  The  patient  loses 
her  strength.  She  gets  easily  tired,  becomes  nervous  and  irritable, 
and  has  often  neuralgic  pain  in  the  localities  described  above  (p.  134), 
and  sometimes  strangely  perverted  sensations  and  hallucinations.1  She 
loses  her  appetite,  her  nutrition  becomes  insufficient,  she  is  pale,  and 
her  features  have  a  suffering  expression. 

Laceration  of  the  cervix  is  often  accompanied  by  secondary  ster- 
ility, probably  in  consequence  of  the  uterine  catarrh  to  which  it  gives 
rise.  The  hyperplastic  lips  and  the  unyielding  cicatricial  plug  in  the 
angles  between  them  oppose  a  considerable  resistance  to  the  dilatation 
of  the  cervix  in  childbirth,  entailing  a  tedious  and  painful  labor. 

Digital  examination  reveals  the  tear  in  the  cervix,  the  thick,  vel- 
vety everted  mucous  membrane,  often  studded  with  small  hard  bodies 
formed  by  the  obstructed  glands.  Pressure  with  the  nail  in  the 
angle  causes  often  great  pain  on  the  spot  or  in  remote  places. 

The  condition  is  best  seen  by  means  of  Sims's  speculum.  The 
tubular  speculum,  by  pressing  the  lips  apart,  is  apt  to  conceal  the 
true  condition  entirely.  The  bivalve  is  liable  to  make  the  laceration 
and  ectropiurn  appear  larger  than  they  really  are.  In  general,  the 
laceration  is  plainer  to  the  touch  than  to  inspection,  but  when  exposed 
by  means  of  Sims's  speculum  the  original  shape  of  the  cervix  may 
be  approximately  reproduced  by  hooking  a  tenaculum  in  each  lip  in 
front  of  the  red  cervical  membrane,  where  the  os  uteri  was  situated 
before  the  laceration  occurred,  and  pulling  the  two  lips  against  one 
another. 

Diagnosis. — By  the  means  just  indicated  it  is  easy  to  demonstrate 
the  laceration.  Sometimes  the  hyperplasia  of  the  lips  and  the  cystic 
development  may  be  so  great  that  the  diagnosis  from  cancer  may 
become  difficult,  but  the  effect  of  treatment  will  soon  dispel  all  doubt. 

1  A  curious  instance  of  this  kind  is  found  in  my  paper  on  Laceration  of  the  Cervix 
Uteri,  Archives  of  Medicine,  October,  1881.  The  same  paper  contains  a  description 
of  the  microscopical  composition  of  the  tissue  removed  in  trachelorrhaphy,  and  a 
case  illustrating  the  obstetric  indication  for  the  operation. 


398  DISEASES  OF   WOMEN. 

Some  women  have  a  congenital  cleft  of  the  vaginal  portion  in  one 
or  two  places.  The  lips  thus  formed  may  become  the  seat  of  a  chronic 
inflammation,  and  thus  a  condition  may  be  brought  about  in  a  uullip- 
arous  woman  that  is  entirely  like  a  bilateral  laceration.1 

Prognosis. — Many  lacerations  of  the  cervix  heal  spontaneously  and 
give  rise  to  no  trouble.  Sometimes  the  nervous  phenomena  men- 
tioned above  may,  however,  develop  even  if  the  tear  is  completely 
healed.  If  the  laceration  is  neglected  the  whole  constitution  suffers, 
as  we  have  seen  above,  and  even  a  phthisical  condition  may  be  the  end. 
Tears  of  the  cervix  seem  also  decidedly  to  predispose  to  cancerous 
degeneration.  If  properly  treated  the  laceration  and  its  consequences 
may  be  entirely  cured. 

Treatment. — The  prophylaxis  consists  in  abstaining  from  giving 
ergot  or  other  ecbolic  drugs,  from  pressing  on  the  fundus  uteri,  or 
from  using  the  forceps  before  complete  dilatation  has  taken  place. 
On  the  other  hand,  the  use  of  drugs  that  favor  dilatation  of  the  cer- 
vix, such  as  belladonna,  chloral,  and  antipyrin  is  beneficial. 

The  accoucheur  should  not  feel  or  look  for  lacerations  of  the  cervix 
except  in  case  of  arterial  hemorrhage.2  Otherwise  he  exposes  his 
patient  to  infection,  that  may  do  much  more  harm  than  lacerations, 
most  of  which  probably  heal  spontaneously. 

If,  however,  a  fresh  tear  has  been  discovered  and  gives  rise  to 
hemorrhage,  it  should  be  closed  with  sutures.  If  circumstances  do 
not  allow  of  such  an  operation,  a  very  densely  packed  tampon  and  a 
tightly  fitting  T-bandage  suffice  to  arrest  the  hemorrhage. 

Fresh  tears  that  do  not  bleed  may  be  treated  with  antiseptic  vagi- 
nal injections  or  the  application  of  a  strong  solution  of  nitrate  of 
silver  (si-Bi)-3 

Old  tears  are  treated  differently,  according  to  their  size  and  the 
other  local  and  general  conditions.  Small  nicks  round  the  os  may 
be  looked  upon  as  a  nearly  normal  incident  of  childbirth  and  need 
no  treatment. 

Medium  tears  are  often  cured  by  curetting,  and  the  application  of 
liquor  ferri  subsulphatis,  twice  a  week,  or  pledgets  with  glycerite  of 
tannin  (3i-|i),  changed  *  morning  and  evening,  and  the  use  of  hot 
vaginal  injections. 

1  I  have  treated  a  girl  who  was  about  twenty  years  old  and  had  an  anteflexion 
of  the  womb.  The  hymen  was  not  ruptured,  but  very  lax,  probably  in  consequence 
of  masturbation.  The  anterior  vaginal  wall  was  everted.  The  cervix  was  split  into 
an  anterior  and  a  posterior  lip,  which  were  entirely  separated,  and  bent  forward  and 
backward  into  the  fornix.  The  opening  in  the  cervical  canal  formed  a  transverse 
slit  J  inch  wide.  The  anterior  lip  measured  1  inch,  the  posterior  f  inch  in  length. 
The  everted  mucous  membrane  was  edematous,  bled  easily,  and  was  covered  with 
abundant  glairy  mucus. 

*  Garrigues,  "The  Immediate  Closure  of  the  Laceration  of  the  Cervix,"  Amer. 
Jour.  Obstet.,  vol.  xxiv.  No.  11,  1891. 

8  Elwood  Wilson,  Gynecological  Trans.,  1886,  vol.  xi.  p.  92. 


DISEASES  OF  THE   UTERUS.  399 

Unilateral  tears  can,  as  a  rule,  be  treated  successfully  in  a  similar 
way. 

Large  bilateral  tears,  or  even  healed  tears  if  they  cause  neuralgia, 
call  for  operative  help,  an  operation  that  is  called  after  its  inventor 
Emmet's  operation,  trachdorrhapliy  (i.  e.  neck-sewing),  or,  more 
explicitly,  hystero-trachelorrhaphy  (/.  e.  womb-neck-sewing). 

Preparatory  Treatment. — Before  performing  this  operation  the  in- 
flamed mucous  membrane  should,  however,  first  be  treated  with  tinc- 
ture of  iodine,  Monsell's  solution,  chloride  of  zinc  solution,  sulphate 
of  copper  solution,  or  tannin  glycerite,  and  hot  douches.  Cysts  should 
be  pricked  with  a  scarifier  and  painted  with  Churchill's  tincture  of 
iodine.  This  preparatory  treatment  may  take  several  months.  If 
circumstances  do  not  warrant  so  protracted  a  treatment,  the  whole 
mucous  membrane  may  be  excised  at  the  time  of  the  operation. 

Trachelorrhaphy : — The  pubic  hairs  having  been  shaved  off  and  the 
genitals,  inclusive  of  the  vagina,  disinfected,  the  patient  is  placed  in 
the  dorsal  position,  the  legs  tied  with  Robb's  legholder,  and  the  peri- 
neum drawn  back  with  a  single  Sims  speculum  or  my  weight  specu- 
lum (Fig.  177).  A  Schroeder  vaginal  retractor  (p.  211)  helps  often 
considerably  in  making  the  parts  accessible.  I  use  strong  full-curved 
trocar-pointed  needles,  1 J  inches  long,  1^  inches  the  straight  line  from 
end  to  point  (Fig.  184,  g),  and  Crosby's  needle-holder  (Fig.  188). 

I  begin  the  operation  by  seizing  the  lips  separately  with  a  bullet- 
forceps,  pulling  the  uterus  gently  down,  and  inserting  a  strong  linen 
or  silk  thread  through  the  middle  of  each  lip.  These  guys  serve 
to  steady  the  uterus,  separate  or  approach  the  lips,  mark  the  canal 
which  is  to  be  kept  open,  and  they  facilitate  the  operation  very 
much.  Next,  a  tenaculum  is  hooked  into  the  cervical  mucous  mem- 
brane on  one  side  of  the  posterior  lip.  With  a  scalpel  a  piece  is 
cut  off  going  in  under  the  tenaculum,  and  the  strip  is  continued  into 
the  angle  of  the  tear.  Many  use  scissors.  The  great  variety  of  those 
invented  suggests,  however,  that  others  have  had  similar  difficulties  to 
those  experienced  by  the  writer,  until  he  replaced  the  scissors  by  the 
knife.  Often  it  is  easier  to  begin  by  cutting  right  into  the  angle  from 
the  cervical  canal  to  the  vagina  or  vice  versa.  A  corresponding  surface 
is  denuded  on  the  anterior  lip.  Then  similar  strips  are  cut  off  on  the 
other  side,  leaving  an  undenuded  surface  corresponding  to  the  cervical 
canal.  This  ought  to  be  about  half  an  inch  wide  at  the  os,  as  con- 
traction always  takes  place  later,  and  would  result  in  too  narrow  an 
os  if  there  had  not  been  left  tissue  enough.  Particular  care  should  be 
taken  to  remove  the  cicatricial  plug  from  the  angle.  The  cut  surfaces 
bleed  freely,  but  there  is,  as  a  rule,  no  hemorrhage  of  consequence. 

The  result  of  the  cutting  is  that  we  have  four  denuded  surfaces, 
each  two  of  which  are  continuous  in  the  depth  of  the  angle,  and 
between  the  denuded  surfaces  a  trumpet-shaped  undenuded  piece 


400 


DISEASES  OF  WOMEN. 


of  mucous  membrane  is  left  on  the  anterior  and  posterior  lips  of  the 
cervix  (Fig.  232). 

The  second  step  is  to  introduce  the  sutures.     The  first  needle  is 
pushed  in  a  quarter  of  an  inch  outside  of  one  of  the  denuded  surfaces 


FIG.  232. 


Diagram  Illustrating  Trachelorrhaphy  in  a  case  of  Bilateral  Laceration:  A,  posterior  lip ;  B, 
anterior  lip;  C,  cervical  canal  (apparent  os  surrounded  by  red  and  swollen  rnucous  mem- 
brane, which  used  to  be  regarded  as  an  ulcer).  The  numbers  mark  the  order  in  which 
the  sutures  are  inserted.  When  they  are  tied  A  comes  in  contact  with  B  and  forms  the 
real  os  (e,f,  g,  h).  The  reader  can  easily  realize  the  whole  effect  of  the  operation  by  copy- 
ing this  figure  on  a  piece  of  paper  and  folding  it  at  a  line  uniting  D  and  D,  which  repre- 
sents the  angle  between  the  lips. 

of  the  posterior  lip  near  the  angle.  It  is  pushed  transversely  under 
the  denuded  surface  and  made  to  emerge  just  on  the  line  of  demarka- 
tion  between  this  and  the  undenuded  central  portion.  Next,  it  is 
inserted  on  the  corresponding  point  of  the  anterior  lip,  and  carried 
under  the  denuded  surface  and  made  to  emerge  a  quarter  of  an  inch 
outside  of  it,  on  a  point  corresponding  to  the  first  in  which  the  needle 
was  pushed  in.  When  the  point  of  the  needle  emerges  anywhere  the 
assistant  holds  the  counter-pressure  hook  (p.  219)  in  under  it,  and 
presses  against  the  tissues  in  order  to  facilitate  the  passage  of  the 
needle.  The  needle  carries  a  loop  of  linen  thread  (p.  218)  into  which 
is  hooked  a  silver  wire  10  inches  long.  This  is  closed  temporarily 
as  explained  on  p.  219,  and  held  aside  so  as  to  be  out  of  the  way.  As 
a  rule,  three  such  sutures  are  inserted  on  either  side,  and  when  they 
all  are  in  place  they  are  twisted  and  cut  off,  beginning  nearest  the 
angle.  The  ends  ought  to  be  left  at  least  half  an  inch  long,  as  they 
are  apt  to  become  imbedded  and  are  hard  to  find  when  you  want  to 
remove  them.  It  takes  more  time  to  use  silver  wire  than  other  mate- 
rial, but  in  this  particular  operation  I  have  sometimes  found  decided 
advantages  in  using  silver  wire.  Later  I  have  abandoned  silver  wire 
for  silkworm-gut  or  chromicized  catgut,  which  does  away  with  the 
suture-carrier  and  the  twisting. 

Before  and  after  closing  the  sutures  I  thoroughly  irrigate  with 
some  antiseptic  fluid. 


DISEASES  OF  THE   UTERUS.  401 

Originally,  the  operation  was  performed  in  Sims's  position,  but  the 
insertion  of  the  needles  and  disinfection  are  much  facilitated  by  the 
dorsal  position. 

After  having  described  the  most  common  form  of  trachelorrhaphy 
we  must  mention  some  of  the  many  conditions  that  call  for  a  modifi- 
cation of  the  operation. 

Modifications. — If  it  has  been  necessary  to  cut  very  deep  into  the 
angle  between  the  lips,  the  wound  cannot  be  closed  in  a  reliable  way 
by  inserting  the  sutures  from  the  vagina  as  described  above.  Then 
the  uppermost  should  go  much  deeper  in  than  it  is  possible  to  get 
it  when  starting  from  the  vagina.  This  is  obtained  by  using  two 
needles,  each  with  a  loop  of  thread.  One  of  them  is  introduced  from 
the  cervical  canal  and  pushed  out  through  the  posterior  lip,  the  other 
is  in  the  same  way  carried  from  within  outward,  through  the  anterior 
lip.  Next  the  posterior  loop  is  passed  through  the  other,  and  the 
latter  pulled  out  through  the  anterior  lip,  carrying  the  posterior 
loop  with  it.  Finally,  the  suture  is  hooked  into  this  loop  and  carried 
back  through  both  lips. 

In  the  unilateral  tear  only  one  side  is  operated  on. 

In  the  stellate  tear  it  is  sometimes  necessary  to  cut  off  a  whole  lobe 
between  two  fissures  on  one  or  even  both  sides. 

If  there  is  much  glandular  hypertrophy  and  cystic  degeneration,  it 
may  be  necessary  to  remove  the  whole  mucous  membrane  from  one  or 
both  lips.  This  may  be  done  before  the  operation  by  means  of 
Simon's  spoon,  and  hemorrhage  staunched  with  liquor  ferri  or  tam- 
ponade.  The  operation  is  then  postponed  until  the  parts  are  healed 
over.  It  may  also  be  done  at  the  time  of  the  operation  by  omitting 
to  leave  an  undenuded  strip  in  the  center  for  the  canal  or  by  curet- 
ting it.  If  this  is  done  on  both  sides,  some  provision  must  be  made 
for  preventing  the  cervical  canal  from  growing  together.  I  have  used 
an  intra-uterine  glass  stem  for  the  purpose  or  introduced  a  probe  re- 
peatedly during  the  healing  process.  Others  leave  a  silk  thread  or 
reopen  the  canal  by  electrolysis.1 

When  there  is  much  hyperplasia,  so  that  the  lips  stand  far  apart, 
and  when  brought  together  offer  two  convex  surfaces,  it  is  necessary 
to  hollow  the  denuded  surfaces  well  out  in  order  to  approximate 
them. 

If  one  lip  is  longer  than  the  other,  the  position  of  the  angle  must 
be  changed  by  cutting  the  tissues  in  such  a  way  as  to  get  the  angle 
over  on  the  longer  lip,  and  thus  obtain  two  lips  of  the  same  length 
that  will  form  a  regular  os. 

If  besides  the  cervix  the  perineum  is  torn,  we  are  in  general  com- 
pelled to  do  both  operations  at  one  sitting ;  but  if  there  came  second- 

1  Geo.  Engelmann  of  St.  Louis,  Gyn.  Trans.,  1885,  vol.  x.  p.  202,  and  1886,  vol.  xi. 
p.  90. 

26 


402  DISEASES  OF  WOMEN. 

ary  hemorrhage  necessitating  taraponade  the  perineal  work  would  be 
destroyed,  and  if  menstruation  came  on  unexpectedly,  which  some- 
times happens,  it  might  be  hard  to  diagnosticate  (p.  223). 

As  a  rule,  there  is  no  more  hemorrhage  than  that  the  operator  can 
go  on  as  described  above.  If,  in  very  exceptional  cases,  the  circular 
artery  bleeds  considerably, the  deepest  suture  should  be  inserted  im- 
mediately on  the  bleeding  side.  As  soon  as  the  two  lips  are  in  appo- 
sition all  bleeding  stops.  In  rare  cases  it  may  be  necessary  to  cut  out 
a  cicatrice  from  the  foruix  of  the  vagina.  Here,  also,  an  artery  may 
spurt  that  should  be  seized  with  pressure-forceps.  It  will  hardly 
be  necessary  to  tie  any  artery. 

If  the  operator  has  denuded  a  larger  surface  than  he  can  cover 
there  may  come  serious  hemorrhage,  which,  however,  can  be  con- 
trolled with  styptic  cotton  and  a  tampon  of  common  cotton,  and  need 
not  interfere  with  a  perfect  result. 

Great  care  should  be  taken  to  have  a  perfect  line  of  union,  the 
vaginal  mucous  membrane  on  one  lip  coming  in  contact  with  that  of 
the  other.  If  necessary  one  or  two  superficial  catgut  sutures  may  be 
inserted  besides  the  deeper  sutures. 

If  the  lips  of  the  torn  cervix  are  adherent  to  the  vaginal  wall,  the 
adhesions  should  be  separated  sufficiently  to  allow  the  lips  to  be 
brought  together.  The  gap  made  by  the  incision  in  the  vagina  should 
be  packed  with  iodoform  gauze. 

Upon  the  whole,  small  as  the  field  is,  and  free  from  danger  as  the 
operation  is,  if  performed  aseptically,  trachelorrhaphy  requires,  in  my 
opinion,  as  much  judgment  and  skill  as  any  other  gynecological 
operation  I  know  of. 

At  the  end  of  the  operation  I  cover  the  cervix  with  a  long  strip  of 
iodoform  gauze,  packed  loosely  into  the  fornix  of  the  vagina.  The 
patient  may  urinate  herself.  The  bowels  are  kept  open  if  necessary. 
On  the  fourth  and  the  seventh  day  the  tampon  is  changed  and  the 
vagina  swabbed  with  antiseptic  solution.  On  the  tenth  day  the  sutures 
and  the  tampon  are  removed,  and  some  vaginal  injection  administered 
morning  and  evening.  The  patient  stays  nine  more  days  in  bed. 

The  effect  of  the  operation  both  locally  and  as  to  general  health  is 
wonderful.  The  womb  diminishes  in  size,  the  nervous  phenomena 
disappear,  the  patients  grow  fat,  a  new  period  full  of  comfort  and 
blooming  health  follows  in  the  course  of  a  few  months,  and  very 
often  conception  puts  an  end  to  sterility. 

The  stitched  surface  may,  of  course,  be  ruptured  in  a  new  labor, 
just  as  the  intact  cervix  was,  but  very  often  it  goes  uninjured  through 
subsequent  childbirths. 


DISEASES  OF  THE   UTERUS.  403 

CHAPTER  III. 
FOREIGN  BODIES. 

FOREIGN  bodies  are  by  far  not  so  common  in  the  uterus  as  in  the 
vagina.  Still,  occasionally  an  intra-uteriue  instrument,  especially  a 
glass  tube,  may  break  and  the  end  remain  inside,  or  absorbent  cotton 
used  for  applying  drugs  to  the  interior  may  come  off.  Sometimes  a 
leech  applied  through  Fergusson's  speculum  to  the  vaginal  portion 
has  slipped  into  the  interior  of  the  womb.  A  hairpin  used  to  pro- 
duce abortion  has  also  been  found  there.  A  Hodge  pessary  slipped 
from  the  vagina  into  the  cervix  while  the  patient  lifted  another 
person.1 

Treatment. — If  any  object  is  in  the  womb  which  cannot  be  with- 
drawn, the  patient  should  be  anesthetized,  the  cervix  dilated,  and  the 
foreign  body  removed  with  finger,  curette,  or  forceps.  If  it  is  a  liv- 
ing leech,  a  strong  solution  of  table-salt  injected  into  the  womb  will 
make  it  loosen  its  grip.  If  there  is  any  hemorrhage  the  uterus  should 
be  tamponed  with  iodoform  gauze. 


CHAPTER  IV. 
METRITIS. 

METRITIS  is  inflammation  of  the  uterus. 

As  in  vaginitis  a  large  number  of  different  forms  of  metritis  are 
described  according  to  the  special  part  affected,  the  cause,  the  course, 
and  certain  peculiarities.  As  this  is  not  a  treatise  on  morbid  anatomy, 
but  above  all  a  guide  to  the  recognition  of  the  diseases  of  the  female 
genitals  and  their  treatment,  it  would  not  only  lead  us  too  far,  but 
cause  unnecessary  repetition  and  confusion,  if  we  were  to  admit  all 
these  distinctions  as  special  diseases.  We  will  only  mention  such 
varieties  as  are  clinically  distinct  or  call  for  different  treatment. 

In  regard  to  time  and  severity  of  symptoms  we  distinguish  between 
acute  and  chronic  metritis. 

Acute  Metritis. — In  the  acute  inflammation  the  whole  organ — body, 
cervix,  mucous  membrane,  muscular  layer,  and  peritoneal  covering — is 
more  or  less  implicated.  The  peritoneal  inflammation — so-called  pcri- 
metritis — is,  however,  not  always  found,  and  if  found  extends  gener- 
ally to  neighboring  parts  of  the  peritoneum,  and  will,  therefore,  be 
treated  of  under  Pelvic  Peritonitis. 

The  inflammation  of  the  mucous  membrane  is  called  endometritis, 
that  of  the  muscular  layer  parenchymatous  metritis,  that  of  the  cervix 
1  Henry  Heiman,  Med.  Record,  March  17,  1894,  p.  347. 


404  DISEASES  OF  WOMEN. 

has  been  designated  as  cervicitis,  and  that  of  the  raucous  membrane 
of  the  cervix  as  endocervicitis. 

Pathological  Anatomy. — The  whole  uterus  is  enlarged  and  softened, 
the  cut  surface  is  red  with  yellow  points.  The  mucous  membrane  is 
swollen  and  red.  Microscopical  examination  shows  both  in  the  mucous 
membrane  and  between  the  muscle-fibers  an  abundant  infiltration  with 
small  round  cells,  dilated  blood-vessels,  and  masses  of  extravasated 
blood.  The  inflammation  extends  sometimes  to  the  peritoneum  and 
the  pelvic  connective  tissue,  either  through  the  tubes  or  through  the 
lympathics  (p.  60).  Sometimes  it  is  combined  with  vaginitis. 

It  is  doubtful  if  ever  an  abscess  is  formed  in  the  uterine  tissue, 
except  in  puerperal  cases  where  the  metritis  appears  as  part  of  a  more 
comprehensive  infection. 

Etiology. — Menstruation  being  accompanied  by  a  development  that 
has  much  in  common  with  that  of  inflammation,  predisposes  to  the 
latter.  Thus  exposure  to  wet  or  cold  is  more  liable  to  end  in  acute 
metritis  during  the  menstrual  period  than  at  other  times.  Coition 
during  menstruation  may  have  a  similar  effect.  Parturition  and  mis- 
carriage are  the  most  common  causes,  either  through  direct  puerperal 
infection  or  as  a  predisposing  element :  if  a  woman  who  has  recently 
given  birth  to  a  child  or  aborted,  fatigues  herself,  catches  cold,  or 
has  sexual  intercourse,  she  is  more  liable  to  have  an  acute  inflamma- 
tion of  the  womb  than  otherwise.  Coition  ought  not  to  take  place 
before  involution  is  completed — say,  two  months  after  childbirth  and 
one  month  after  early  abortion. 

Acute  metritis  may  be  brought  on  by  any  gynecological  operation, 
even  the  mere  introduction  of  a  sound,  and  still  more  easily  by  curet- 
ting, or  by  the  irritation  caused  by  an  intrauterine  stem  or  even  a  badly- 
fitted  vaginal  pessary.  Trachelorrhaphy  or  incision  of  the  cervix  has 
often  led  to  endometritis  extending  through  the  tubes  to  the  peritoneal 
cavity  and  ending  fatally.  Retained  blood  may  become  decomposed 
and  cause  acute  metritis.  The  true  agent  in  all  these  cases  is  doubt- 
less the  introduction  of  pathogenic  microbes,  for  by  proper  antiseptic 
precautions  the  evil  may  be  avoided. 

Acute  metritis  appears  sometimes  in  the  exanthematous  fevers, 
typhoid  fever,  cholera,  acute  yellow  atrophy  of  the  liver,  phosphorus- 
poisoning,  and  in  persons  affected  with  syphilis. 

As  we  have  seen  above  (pp.  131  and  291),  gonorrheal  infection 
invades  sometimes  the  uterus. 

Symptoms. — Acute  metritis  is  accompanied  by  fever,  a  sensation  of 
heat  in  the  pelvis,  bearing-down  pain,  a  painful  sensation  of  contrac- 
tions called  cramps,  or  pain  extending  up  to  the  lumbar  region. 
Sometimes  the  patient  complains  of  vomiting,  diarrhea,  dyschezia, 
and  dysuria.  Often  she  suffers  from  suppressio  mensium  or  menor- 
rhagia,  or  has  a  purulent  discharge  from  the  uterus.  In  gonorrheal 


DISEASES  OF  THE   UTERUS.  405 

metritis  t'here  is  especially  an  abundant  secretion  of  thick  creamy, 
often  blood-tinged  pus,  teaming  with  gonococci.  The  abdomen  is 
tympanitic  and  tender. 

Vaginal  examination  reveals  a  hot  vagina,  a  swollen,  congested 
cervix,  with  patulous,  often  eroded,  os,  and  a  large,  soft,  tender 
body. 

Prognosis. — In  most  cases  the  disease  ends  in  recovery  in  the  course 
of  from  two  to  four  weeks.  Repeated  attacks  of  acute  metritis  are, 
however,  liable  to  end  in  chronic  metritis.  The  possibility  of  the 
extension  of  the  inflammation  to  the  tubes  and  the  peritoneal  cavity, 
especially  in  gonorrheal  and  septic  metritis,  must  also  make  us  cau- 
tious in  our  prognostication. 

Treatment. — Prophylaxis. — A  perusal  of  the  causes  of  acute  metri- 
tis gives  the  necessary  indications  in  regard  to,  how  to  avoid  the  dis- 
ease. At  the  time  of  menstruation,  in  the  puerperal  state,  and  after 
abortion,  women  should  be  particularly  careful  to  avoid  too  great 
bodily  exertion  and  exposure  to  cold.  They  should  abstain  from 
sexual  intercourse.  Obstetricians  and  gynecologists  should  use  all 
antiseptic  precautions,  even  in  normal  deliveries,  as  well  as  small 
gynecological  manipulations  and  operations. 

Curative  Treatment. — The  patient  should  stay  in  bed.  An  ice-bag 
or  ice-\vater  coil  should  be  applied  over  the  symphysis  (p.  187), 
except  when  the  cause  is  suppression  of  menses  by  exposure  to  cold. 
In  the  latter  case  a  warm  poultice  or  hot-water  bag  is  substituted. 

If  there  is  no  bleeding,  some  bloodletting  by  means  of  leeches, 
the  artificial  leech,  or  simple  scarification  (p.  186)  sometimes  affords 
considerable  relief;  but  all  these  manipulations  necessitate  the  use  of 
a  speculum,  and,  if  the  tenderness  is  great,  this  does  more  harm  than 
good. 

Vaginal  douches  of  plain  warm  water  should  be  administered 
three  times  a  day  or  oftener.  In  these  acute  cases  lukewarm  water 
(100°-105°  F.)  has  often  a  more  soothing  effect  than  the  hot  (110°- 
115°).  The  addition  of  flaxseed  or  slippery  elm  increases  perhaps 
this  effect  of  the  douche  somewhat  (p.  1 72). 

A  lukewarm  sitz-bath  (p.  187)  once  or  twice  a  day  or  a  general 
warm  bath  every  other  day  is  also  useful,  if  the  slight  movements 
inseparable  from  these  procedures  do  not  hurt  the  patient.  Anodynes 
are  best  given  as  opium  suppositories  (p.  226).  Five  grains  of  qui- 
nine should  be  given  every  four  hours,  and  the  bowels  kept  open. 

When  the  most  acute  symptoms  have  subsided,  the  ice-bag  may  to 
advantage  be  exchanged  for  Priesznitz's  compress  (p.  187),  tincture 
of  iodine  may  be  painted  on  the  abdomen  and  on  the  roof  of  the 
vagina  (p.  188),  and  glycerin  tampons  (p.  178)  may  be  introduced 
into  the  vagina.  If  the  discharge  is  purulent,  the  uterus  should  bo 
curetted. 


406 


DISEASES  OF  WOMEN. 


Gonorrheal  raetritis  necessitates  a  more  active  treatment.  The  ute- 
rus should  be  washed  out  (p.  172)  at  least  once  a  day  with  a  solution 
of  corrosive  sublimate  (1  :  3000),  permanganate  of  potash  (1  :  1000). 
or  chloride  of  zinc  (1 : 100).  Twice  a  week  the  interior  of  the  uterus 
should  be  painted  all  over  with  a  solution  of  chloride  of  zinc  (20  per 
cent.)  or  nitrate  of  silver  (1  : 12).  Some  use  curetting  (p.  176).  A 
milder  treatment,  with  a  somewhat  similar  effect,  consists  in  packing 
the  uterus  once  or  twice  with  iodoform  gauze  (p.  180)  in  order  to 
remove  all  pus  and  some  of  the  epithelium,  and  finally  leaving  a 
strip  well  dusted  with  iodoform  in  the  uterus.  Far  from  causing 
pain,  it  seems  to  have  a  soothing  effect. 

Diphtheritic  Metritis. — A  particular  variety  of  the  acute  metritis  is 

the  diphtheritic,  in  which  there  is  a  yellow  exudation  in  and  on  the 

endometrium.     This  condition  is  mostly  due 

FIG.  233.  to  puerperal  infection,  but  is  also  found  as 

/f"  part  of  general  diphtheria.     It  occurs  com- 

/"  bine*!  with  gangrene  of  the  vagina  (p.  352)  in 

Hi,  scarlet  fever,  typhoid  fever,  cholera,  and  other 

|H  infectious  diseases. 

If  In  puerperal  cases  the  diphtheritic  infiltra- 
tion may  extend  in  a  layer  from  the  endome- 
trium to  the  neighborhood  of  the  peritoneum, 
cutting  off  a  large  part  of  the  muscular  tissue, 
which,  after  weeks  or  months,  is  expelled  as  a 
pear-shaped  body  (Fig.  233),  a  condition  which 
is  little  known,  but  of  which  I  have  observed 
and  described  under  the  name  of  dissecting 
metritis  not  less  than  eight  cases.2 

Diphtheritic  metritis  is,  as  a  rule,  combined 
with  a  similar  condition  in  the  vulva  and  the 
vagina,  and  may  be  made  visible  when  it  at- 
tacks the  cervix.     Dissecting  metritis  cannot 
be  diagnosticated  before  the  loose  body  is  ex- 
Dissecting  Metritis.i          pel  led,  but  its  existence  may  be  surmised,  if 
after  diphtheritic  vaginitis  and  cervicitis  there 
continues  an  abundant  purulent  discharge  from  the  uterus. 

If  the  cervix  is  attacked,  its  whole  inner  surface  should  be  thor- 
oughly painted  once  with  chloride-of-zinc  solution,  50  per  cent.  The 
uterus  should  be  washed  out  with  carbolized  water  once  a  day.  An 
iodoform  pencil 

1  Specimen  expelled  by  B.  R.  at  Maternity  Hospital,  on  Oct.  20,  1883.    This  was 
the  eighth  case  of  the  report  published  in  N.  Y.  Med.  Record,  vol.  xxiv.  .p.  664. 
The  figure  taken  from  a  photograph  is  a  little  below  natural  size. 

2  Garrigues,  "  Dissecting  Metritis,"  New  York  Medical,  Journal,  1882,  vol.  xxxvi.  p. 
537;  Archives  of  Medicine,  April,  1883;  and  Archivfiir  Gyndkologie,  1890,  vol.  xxxviii. 
p.  511. 


DISEASES  OF  THE   UTERUS.  407 

1^.  lodoformi,  3v; 

Amyli,  3ss ; 

Glycerini,  fl.  3ss ; 

Acacise,  3J. 

M.     Sig.  Divide  in  three  suppositories  of  the  size  and  shape  of 
the  little  finger. 

should  be  introduced  up  to  the  fundus  and  left  to  melt.  The  internal 
treatment  consists  in  the  administration  of  quinine,  stimulants,  and 
chloride  of  iron. 

Some  recommend  in  severe  puerperal  infection  hysterectomy  and 
removal  of  the  appendages,  either  by  the  vaginal  method  or  abdom- 
inal section.  The  operation  is  said  to  be  especially  indicated  when 
there  are  foci  of  suppuration  or  infection  in  the  uterine  body,  an  in- 
fected endometrium,  persistent  metrorrhagia,  or  widespread  suppura- 
tion and  disintegration  of  the  broad  ligaments.  In  the  writer's  ex- 
perience these  patients  are  in  most  cases  too  weak  to  stand  so  serious 
an  operation,  and  the  operation  itself  spreads  often  the  infection.  In 
the  majority  of  cases  better  results  may  be  expected  from  medical 
treatment,  opening  and  draining  of  abscesses,  etc.  More  radical  ope- 
rations are  often  to  advantage  postponed  till  the  patient  has  gained 
more  strength. 

B.  Chronic  Metritis. — While  we  have  treated  of  the  acute  form  of 
metritis  as  one  entity  without  distinguishing  between  the  inflamma- 
tion of  the  mucous  membrane  and  that  of  the  muscular  tissue,  in 
regard  to  the  chronic  form  of  inflammation  of  the  uterus,  it  is  bet- 
ter to  describe  endometritis  and  parenchymatous  metritis  separately. 
It  is  true  that  the  inflammation  of  the  mucous  membrane  always 
extends  somewhat  into  the  muscular  layer,  and  that  an  inflammation 
of  the  latter  always  implicates  the  former,  but  still  there  are  marked 
clinical  differences  between  the  two,  and  certain  points  in  the  treat- 
ment apply  only  to  one  or  the  other. 

1.  Chronic  Endometritis. — Pathological  Anatomy. — In  the  chronic 
form  of  endometritis  the  mucous  membrane  of  the  uterus  is  swollen, 
soft,  friable,  of  dark  red  or  slate  color.  In  some  places  are  seen  ecchy- 
moses.  On  account  of  the  swelling  the  mucous  membrane  does  not 
find  room  enough  in  the  uterus  and  bulges  out  through  the  os,  form- 
ing a  so-called  ectropium.  The  glands  of  the  cervix  become  occluded 
and  form  cysts  most  of  which  are  small  as  hemp-seed  or  peas,  and 
shine  with  a  white  or  yellow  color  through  the  surface  of  the  vaginal 
portion.  In  olden  time  these  retention  cysts  were  mistaken  for  the 
human  ovulurn  and  are  yet  known  under  the  name  of  ovufa  of  Xa~ 
both.  Occasionally  these  cervical  cysts  acquire,  however,  the  size  of 
a  cherry.  When  pricked  open  a  thick  colorless  fluid,  like  the  raw 
white  of  an  egg,  flows  out  from  them.  The  interior  of  the  body  has 


408  DISEASES  OF  WOMEN. 

lost  its  even  smoothness,  and  is  raised  in  ridges  or  in  papillary  growths, 
or  long  club-shaped  polypi  hang  down  from  the  fundus  and  the  side 
walls.  This  has  been  described  under  the  name  of  hyperplastic  or 
fungous  endometritis.  Similar  mucous  polypi  form  in  the  mucous 
membrane  of  the  cervix  and  may  hang  out  from  the  os  as  peduncu- 
lated  tumors. 

Around  the  os,  on  the  outer  surface  of  the  vaginal  portion,  is  found 
a  red  velvety  area,  and  similar  red  spots  may  be  found  further  out  on 
the  vaginal  portion,  apart  from  the  os.  They  are  often  called  erosions, 
and  they  form  what  is  known  as  a  granular  os.  They  used  erroneously 
to  be  called  ulcers  of  the  cervix,  an  expression  that  is  yet  often  used 
by  patients. 

Microscopical  examination  shows  that  the  swelling  of  the  mucous 
membrane  in  chronic  endometritis  is  due  to  a  great  development  of 
its  glands,  to  infiltration  with  round  cells,  and  to  dilatation  of  the 
blood-vessels.  The  glands  penetrate  into  the  muscular  layer.  When 
this  considerable  development  of  glands  takes  place,  the  condition  is 
sometimes  designated  as  benign  adenoma  as  opposed  to  malignant  ade- 
noma, which  is  beginning  cancer  of  the  mucous  membrane. 

The  fungoid  growths  on  the  inside  of  the  uterus  are  sometimes 
nearly  exclusively  formed  by  glands ;  in  others  they  consist  of  round 
cells  like  the  granulations  on  a  wound ;  and  in  a  third  variety  they 
are  almost  entirely  composed  of  dilated  blood-vessels.  In  some 
places  the  formation  of  connective  tissue  gets  the  upper  hand,  and 
the  glands  become  atrophic  or  disappear.  A  similar  difference  is 
observed  on  different  points  of  the  membrane,  if  it  remains  compara- 
tively smooth. 

The  so-called  erosions  are  due  to  a  change  in  the  epithelium  cover- 
ing the  vaginal  portion,  which  normally  is  flat  like  that  of  the  vagina, 
but  becomes  columnar.  In  the  interior  is  found  an  infiltration  with 
round  cells,  as  in  all  inflammations.  By  invagination  the  epithelium 
forms  bays  and  tubules,  which  constitute  new  glands  and,  when  they 
become  closed,  are  transformed  into  cysts. 

Etiology. — Many  points  have  already  been  discussed  in  the  chapter 
on  Etiology  in  General  (pp.  127-131),  and  the  reader  is  referred  to 
what  is  stated  there  about  hyperemia  of  the  pelvic  organs,  con- 
stipation, exposure  to  cold,  improper  dress,  neglect  during  men- 
struation, certain  abnormalities  in  regard  to  coition,  puerperal  in- 
fection, and  abortion. 

The  influence  of  gonorrhea  has  been  spoken  of  on  pp.  131  and 
291,  and  we  have  seen  how  it  may  cause  acute  metritis  (p.  404), 
but  after  the  acute  stage  is  over  it  may  remain  as  a  chronic  inflam- 
mation. 

During  childbirth  the  cervix,  and  especially  its  mucous  membrane, 
is  subjected  to  such  pressure  and  abrasions  that  often  a  chronic  endo- 


DISEASES  OF  THE   UTERUS.  409 

cervicitis  follows.  This  is  especially  the  case  if  the  cervical  portion 
is  torn  (p.  396). 

Parts  or  the  whole  of  the  decidua  may  remain  after  childbirth  and 
abortion  and  continue  to  live  as  part  of  the  endometrium,  a  condition 
that  has  been  described  as  decidual  endometritis. 

Old  age  gives  rise  to  a  peculiar  form  of  endometritis  called 
atrophic  endometritis.  The  normal  columnar  epithelium  becomes 
changed  to  an  irregular  horny  one,  more  like  the  flat  epithelium  of 
the  vagina.  There  is  a  profuse  purulent  discharge.  Sometimes  the 
opposite  walls  grow  together,  especially  at  the  internal  os,  which  gives 
rise  to  senile  pyometra. 

Symptoms. — A  prominent  symptom  is  pain.  In  the  general  divi- 
sion of  this  book  we  have  enumerated  the  order  of  frequency  with 
which  a  neuralgic  pain  is  found  in  certain  localities  (p.  134).  Besides, 
the  patient,  as  a  rule,  complains  of  "  bearing  down,"  a  disagreeable 
sensation  of  heaviness  extending  from  the  interior  of  the  pelvis  to  the 
external  genitals,  and  often  of  "  cramps,"  a  painful  feeling  of  muscu- 
lar contraction  of  the  uterus  caused  by  retention  of  blood  or  mucus 
above  the  internal  os.  Sometimes,  although  the  ophthalmologist  finds 
no  fault  in  her  eyes,  she  complains  of  pricking  pains  in  them,  of  weak 
eyesight  and  photophobia,  often  combined  with  pain  in  the  occiput, 
where  the  visual  centers  are  located. 

It  is  not  rare  that  a  feeling  of  discomfort  necessitates  frequent  mic- 
turition although  the  urine  is  normal,  a  condition  designated  as 
irritable  bladder. 

As  a  rule,  the  menstrual  discharge  is  preceded  and  accompanied  by 
more  or  leas  severe  dysmenorrhea  (p.  242). 

Secondly,  abnormal  loss  of  blood  from  the  uterus  is  of  frequent 
occurrence,  and  easily  explained  by  the  vascular  development  de- 
scribed in  the  paragraph  on  morbid  anatomy.  There  may  be  meu- 
orrhagia  (p.  245)  or  metrorrhagia  (p.  247),  or  both,  and  often  pro- 
tracted menstruation,  the  menstrual  process  extending  over  an  unusual 
number  of  days,  although  perhaps  the  total  loss  of  blood  does  not 
exceed  the  normal  quantity.  When  loss  of  blood  is  a  prominent 
feature  the  condition  has  been  described  as  hemorrhagic  endometritis. 

In  very  weak  patients  endometritis  is,  on  the  other  hand,  occa- 
sionally accompanied  by  amenorrhea. 

A  third  symptom  that  brings  the  patient  to  seek  help  is  leucorrhea, 
which  is  easily  accounted  for  by  the  hyperplasia  of  the  normal  glands 
and  the  constant  formation  of  new  ones.  The  fluid  secreted  by  the 
cervix  is  like  raw  white  of  an  egg  (p.  250),  that  from  the  interior  of 
the  body  is  more  milky.  Both  are  alkaline,  and  both  may  become 
purulent,  which  is  especially  the  case  in  gonorrheal  and  atrophying 
endometritis.  As  to  the  microscopical  composition,  see  p.  250.  If 
the  discharge  is  at  all  abundant,  it  weakens  the  constitution  (p.  251). 


410  DISEASES  OF  WOMEN. 

When  leucorrhea  predominates,  the  disease  has  been  called  catarrhal 
endometritis  or  catarrh  of  the  uterus. 

In  some  patients  there  is  a  very  free  discharge  of  a  muco-serous 
fluid,  a  condition  called  hydrorrhea.  At  times  the  secretion  may  be 
retained  above  the  internal  os,  probably  on  account  of  the  swelling 
of  the  mucous  membrane  or  a  spasmodic  contraction  of  the  surround- 
ing muscular  tissue.  The  uterus  may  then  become  quite  distended, 
and  the  patient  has  considerable  pain  until  the  obstacle  gives  way,  and 
the  accumulated  fluid  rushes  out  in  a  gush,  when  she  feels  relieved 
until  the  same  process  repeats  itself.  Apart  from  pregnancy  hydror- 
rhea is  a  rare  disease.1 

The  hydrorrhea  of  pregnancy,  hydrorrhea  gravidarum,  on  the  con- 
trary, is  rather  common.  Watery  fluid  may  be  discharged  any  time 
during  pregnancy,  but  it  is  most  common  during  the  last  month  of 
gestation,  and  gives  often  rise  to  the  erroneous  supposition  that  the 
"  waters  have  broken." 

A  similar  condition  is  sometimes  found  after  childbirth — puer- 
peral hydrorrhea.  It  is  then  commonly  due  to  the  retention  of  a 
portion  of  the  placenta  or  of  clots,  but  a  polypus  may  produce  like 
results.2 

The  patient  afflicted  with  endometritis  loses  her  appetite,  and  suf- 
fers often  from  nausea,  dyspepsia,  and  constipation.  She  becomes 
weak  and  pale,  with  black  rings  under  her  eyes. 

Some  patients  complain  of  a  feeling  of  oppression  in  breathing. 
Some  have  palpitations. 

The  nervous  system  suffers  much.  These  patients  are  quite  fre- 
quently despondent  and  melancholy.  I  have  seen  cases  of  acute 
mania  and  epilepsy.  The  group  of  symptoms  classed  as  hysteria  is 
so  rare  that  it  is  doubtful  if  there  is  a  causative  relation  between  it 
and  endometritis. 

An  inflamed  endometrium  does  not  seem  to  be  a  favorable  ground 
for  the  implantation  and  development  of  the  ovum.  The  abundant 
leuchorrhea  helps  also  perhaps  to  expel  it.  So  much  is  sure  that 
patients  afflicted  with  endometritis  often  are  sterile,  or  if  they  con- 
ceive they  have  a  tendency  to  abortion.  It  is  also  claimed  that  pla- 
centa praevia  may  be  caused  by  it,  the  ovum  sinking  down  to  the  os 
internum  before  it  becomes  fastened  to  the  endometrium. 

By  vaginal  examination  we  find,  in  most  cases,  at  least  in  women 
who  have  borne  children,  the  os  patulous,  velvety,  or  granular,  often 
studded  with  small,  round,  hard  bodies  (pvula  of  Naboth).  In  nul- 

1  I  have  seen  a  case  in  which  the  uterus  was  purple,  slightly  tender,  and  meas- 
ured, when  the  patient  consulted  me,  3o  inches,  but  before  that  it  had  been  ,as  much 
as  5  inches,  as  measured  by  other  gynecologists  of  this  city.     Her  discharge  was  so 
copious  that  "  she  used  forty  diapers  a  day,  that  it  wetted  sheets,  and  that  she  could 
pass  it  on  a  bed-pan  and  fill  bottles  with  it." 

2  R.  Barnes,  Diseases  of  Women,  London,  1873,  p.  81. 


DISEASES  OF  THE   UTERUS.  411 

liparous  women,  on  the  other  hand,  the  external  os  is  often  too  nar- 
row, and  the  secretion  accumulates  in  the  cervix  or  in  the  body  of  the 
uterus  or  in  both  simultaneously. 

The  cervix  is  quite  commonly  enlarged,  either  too  soft,  when  the 
cellular  infiltration,  the  formation  of  glands  and  cysts,  and  the  dila- 
tation of  the  blood-vessels  predominate,  or  too  hard,  when  the  hyper- 
plasia  of  connective  tissue  has  caused  atrophy  or  disappearance  of  the 
softer  structures.  The  uterus  is  tender  on  pressure. 

The  introduction  of  the  sound  and  dilator  is  unusually  painful  and 
often  causes  some  bleeding.  By  moving  the  sound  along  the  interior 
surface  it  is  often  felt  to  be  rough  or  the  seat  of  polypi. 

Diagnosis. — In  lumbo-abdominal  neuralgia  certain  parts  of  the 
uterus,  especially  on  the  level  with  the  internal  os  may  be  tender  on 
pressure,  but  then  all  the  other  symptoms,  especially  hemorrhage  and 
leucorrhea,  are  absent. 

A  fibroid  tumor  often  causes  hemorrhage  and  leucorrhea,  but  the 
presence  of  the  tumor  can  be  made  out  by  bimanual  examination.  If 
it  is  %  fibroid  polypus,  it  can  be  felt  with  the  sound. 

The  diagnosis  from  the  early  stage  of  cancer  may  be  difficult.  In 
cancer  we  find,  however,  such  friability  of  the  tissue  that  parts  can  be 
scraped  oif  with  the  nail,  or  are  spontaneously  expelled  from  the  inte- 
rior of  the  womb,  which  is  never  the  case  in  endometritis.  On  the 
other  hand,  this  soft  tissue  is  surrounded  by  one  that  is  much  harder 
than  in  mere  inflammation.  Cancer  is  accompanied  by  a  profuse 
discharge  of  a  watery  fluid  or  thin  pus  with  a  peculiar  pungent  and 
offensive  odor.  As  to  hemorrhage,  when  the  patient  is  in  the  prime 
of  life,  has  a  subinvoluted  uterus,  and  suffers  merely  from  menorrha- 
gia,  the  probability  is  in  favor  of  hyperplastic  endometrits,  and  against 
malignant  disease.  On  the  other  hand,  bleeding  after  the  menopause 
is  a  very  suspicious  symptom.  Many  lay  much  stress  upon  irregular 
bleeding  in  the  intermenstrual  period,  especially  after  coition,  but  I 
have  often  seen  this  in  cases  of  lacerated  cervix  with  ectropion.  Pain 
is,  as  a  rule,  absent  in  beginning  cancer,  but  sometimes  the  patient  has 
vague  shooting  pains  in  the  pelvis.  Cancerous  tissue  is  well  differenti- 
ated from  the  surroundings,  forming  a  glistening  prominence  not  unlike 
currant  jelly.  The  effect  of  treatment  will  soon  dispel  all  doubt. 
The  diagnosis  is  made  sure  by  cutting  out  a  piece  of  the  suspicious 
tissue  from  the  cervix,  imbedding  it  and  preparing  microscopical 
specimens  of  it.  In  the  same  way  the  malignant  or  benign 
nature  of  scrapings  from  the  interior  of  the  womb  is  ascertained. 
Mere  "teasing"  with  two  needles  does  not  furnish  conclusive 
specimens. 

Prognosis. — Chronic  endometritis  is  at  best  a  very  tedious  disease, 
and  it  is  not  safe  to  promise  more  than  improvement.  This  applies 
particularly  to  the  catarrhal  discharge.  But  even  this  is  sometimes 


412  DISEASES  OF  WOMEN. 

completely  cured.  As  to  conception,  the  prognosis  should  be  still 
more  reserved,  especially  in  cases  of  catarrhal  endometritis  involving 
the  body  of  the  womb. 

Hemorrhage  may  undermine  the  constitution  and  even  prove  fatal, 
but  in  this  respect  our  therapeutic  resources  are  manifold  and  powerful. 

As  to  pain  and  other  nervous  phenomena,  the  outlook  is  favorable. 

Treatment. — What  prophylactic  measures  are  to  be  taken,  is  self- 
evident  by  reference  to  the  above  paragraph  on  etiology.  Here  we 
will  only  notice  the  importance  of  removing  the  endometrium  with  a 
curette  after  abortion,  and  of  not  allowing  pieces  of  placenta  or  mem- 
brane to  stay  behind  after  delivery. 

In  patients  affected  with  gonorrhea  of  the  urethra  and  vagina,  the 
extension  of  the  disease  to  the  uterus  may  perhaps  be  prevented  by 
the  use  of  a  tampon  soaked  in  the  following  solution :' 

1^.  Acidi  tannici, 

lodoformi,  da  3n ; 

Glycerini,  3v. — M. 

Patients  affected  with  chronic  endometritis  need  a  good  deal  of 
rest.  Gymnastics,  dancing,  bicycling,  machine-sewing,  and  similar 
fatiguing  movements,  make  their  condition  worse.  Moderate  exercise 
in  the  open  air  is  good,  but  the  patient  ought  never  to  walk  so  much 
as  to  increase  her  pain.  In  order  to  avoid  pelvic  congestion,  she 
should  abstain  as  much  as  possible  from  sexual  intercourse.  For  the 
same  reason  the  bowels  should  be  kept  open  if  she  is  constipated  (p. 
225).  An  elastic  belt  surrounding  the  whole  abdomen  (p.  190)  is 
often  useful  in  stout  women  by  shifting  over  on  the  spinal  column 
and  the  lower  extremities  some  of  the  pressure  exercised  on  the  uterus 
by  the  intestines  and  other  abdominal  organs. 

A  warm  bath  (p.  187)  twice  a  week  has  often  a  very  soothing  effect 
on  the  nerves,  and  probably  withdraws  blood  from  the  uterus  by  dilat- 
ing the  capillaries  of  the  skin.  Warm  sitz-baths  have  a  similar 
effect.  By  the  use  of  the  bath-speculum  (p.  187)  this  may  still 
be  enhanced.  Sea-bathing,  shower-,  sponge-,  sheet-,  or  towel-baths, 
or  a  regular  hydrotherapeutic  treatment  is  excellent  in  combating 
catarrh,  hemorrhage,  and  debility.  Certain  spas  (p.  188)  have  a  repu- 
tation for  being  beneficial  in  chronic  endometritis. 

The  disease  being  of  long  duration,  we  should  use  anodynes 
(p.  226)  very  sparingly.  Backache  is  temporarily  relieved  by  rub- 
bing the  region  with  a  mixture  of  1  part  of  chloroform  with  3  parts 
of  olive  oil  four  times  a  day.  The  pain  in  the  eyeballs  accompanying 
asthenopia  disappears  rapidly  under  the  use  of  a  douche  of  cold  water 
directed  three  times  a  day  for  five  minutes  against  the  closed  eyes. 
1  H.  Fritsch  in  BUlroth's  und  Luecke's  Handb.  d.  Frauenkr.,  vol.  i.  p.  1043. 


DISEASES  OF  THE   UTERUS.  413 

Certain  fountain-syringes  are  accompanied  by  a  nozzle  in  the  shape 
of  the  rose  of  a  watering-pot,  which  answers  the  purpose.  With  this 
treatment  I  combine,  as  a  rule,  scarification  of  the  cervical  portion 
and  the  administration  of  tonics  (p.  225). 

For  irritable  bladder  I  use  the  following  mixture : 

3$j.  Tinct.  belladonna?,  3\j  ; 

Liq.  potassse,  3J  ; 

Aquam,  ad  3iv. 

M.  Sig.  1  teaspoonful  in  a  wineglassful  of  water  3  times  a  day, 
between  meals. 

In  regard  to  hemorrhage  the  reader  is  referred  to  what  has  been 
said  on  p.  246. 

If  the  measures  described  there  fail  to  check  the  uterine  hemor- 
rhage, the  uterine  artery  may  be  ligated  on  both  sides  (p.  182). 
Sometimes  salpingo-oophorectomy  has  been  performed,  and  even 
hysterectomy. 

If  in  hyperplastic  endometritis  the  endometrium  is  studded  with 
prominences,  curetting  (p.  176)  has  a  prompt  effect.  If  the  whole 
membrane  is  swollen,  the  intra-uterine  chemical  galvano-cauterization 
according  to  Apostoli's  method  is  excellent.  The  galvano-cautery 
has  also  been  used  for  this  purpose,  but  is  probably  an  unnecessarily 
harsh  treatment. 

The  treatment  of  amenorrhea  is  discussed  on  p.  240.  It  occurs 
sometimes  for  from  one  to  four  months  after  curetting,  and  should 
then  not  be  interfered  with,  as  it  is  a  beneficent  pause  after  the  drain 
on  the  system  for  which  the  curetting  was  done. 

For  the  treatment  of  leucorrhea  directions  are  found  on  p.  251. 
Since  we  have  seen  above  how  the  glands  of  the  mucous  membrane 
become  enlarged  and  dip  into  the  muscular  layer,  it  is  easy  to  under- 
stand how  fruitless  often  all  applications  prove,  and  how  important  it 
is  to  combine  general  with  local  treatment. 

Curetting,  chemical  irritants,  the  actual  cautery,  and  other  powerful 
revulsives,  work  not  only  by  removing  diseased  tissue,  but  the  tissue  is 
returned  to  a  medullary  state,  and  taking  a  new  start  the  new-formed 
tissue  may  become  healthy. 

Oppression  and  palpitations  are  treated  with  bromides,  especially 
monobromated  camphor  (gr.  i-x,  t.  i.  c?.,  in  emulsion  or  capsules). 

Ovula  Nabothi  are  pricked  open  and  then  painted  with  tincture  of 
iodine.  Exceptionally,  the  whole  cervical  portion  may  be  one  agglom- 
eration of  cysts,  which  do  not  yield  to  this  treatment,  Then  they 
should  gradually  be  destroyed  with  a  needle-shaped  Paqueliu's  cau- 
tery or  galvano-cautery. 

For  erosions  there  is  no  better  treatment  than  to  bathe  the  vaginal 


414  DISEASES  OF  WOMEN. 

portion  in  a  tubuliforra  speculum  for  a  couple  of  minutes  with  acidum 
pyrolignosum  rectificatum  twice  a  week ;  but  this  substance  has  such 
a  pungent  odor  that  it  is  disagreeable  to  most  people.  A  10  per  cent, 
solution  of  sulphate  of  copper  applied  in  a  similar  way  for  a  few  min- 
utes two  or  three  times  a  week  is  also  very  good.  Erosions  may  also 
be  treated  with  carbolic,  chromic,  or  nitric  acid,  followed  by  a  solution 
of  bicarbonate  of  soda  in  order  to  neutralize  the  superfluous  acid. 
Injections  of  chloride  of  zinc,  chloride  or  subsulphate  of  iron,  and 
nitrate  of  silver  are  also  valuable.  I  often  combine  curetting  by 
means  of  Simon's  sharp  spoon  with  the  application  of  liquor  ferri 
chloridi. 

I  have  obtained  excellent  results  by  applying  to  the  eroded  os, 
through  Cusco's  speculum,  the  positive  pole  of  a  galvanic  battery  in 
the  shape  of  a  ball  of  gas-carbon  wound  with  very  little  cotton, 
squeezed  nearly  dry.  It  is  used  for  five  minutes  with  as  strong  a 
current  as  the  patient  can  stand  (about  40  milliamp^res).  It  leaves 
an  eschar  followed  by  suppuration.  A  few  such  applications  re- 
peated once  a  week  produce  a  healthy  mucous  membrane  in  shorter 
time  than  any  astringent.  Apostoli  has  constructed  a  special  elec- 
trode for  the  purpose  (p.  234). 

If  the  cervix  is  lacerated,  trachelorrhaphy  should  be  performed 
(p.  399). 

In  the  interior  of  the  body  of  the  uterus  the  above-named  acids 
and  astringents  are  also  used.  The  substances  I  personally  use  for 
treating  the  endometrium  are  Churchill's  tincture  of  iodine,  chloride 
of  zinc,  nitrate  of  silver,  and  chloride  of  iron,  and  I  apply  them  all 
on  absorbent  cotton  wound  around  Budd's  applicator  (p.  1 70). 

Iodine  is  the  mildest  and  the  most  generally  useful ;  chloride  of 
iron  is  best  in  the  hemorrhagic,  chloride  of  zinc  and  nitrate  of  silver 
in  the  catarrhal  form. 

Besides  the  intra-uterine  application,  I  paint  the  vaginal  roof  with 
tincture  of  iodine  (p.  170),  which  probably  acts  as  a  counter-irri- 
tant. 

The  patient  herself  introduces  a  pledget  with  glycerin  morning  and 
evening  (p.  178).  As  we  want  the  iodine  to  enter  the  tissue  by  endos- 
mosis,  and  glycerin  causes  a  powerful  exosmosis,  it  is  better  not  to 
introduce  the  pledget  immediately  after  painting  the  vagina. 

As  an  astringent  on  a  spongy  cervix,  glycerite  of  tannin  is  very 
good  (p.  178).  Duke  recommends  boracic  acid  in  powder  applied 
with  a  tube  and  piston  (p.  171). 

Scarification  is  used  not  only  for  opening  and  destroying  cervical 
cysts,  but  also  to  give  exit  to  some  blood.  When  the  uterus' appears 
congested,  this  procedure  gives  often  great  relief  (p.  186). 

If  the  external  os  is  too  narrow,  mucus  often  accumulates  in  the 
cervix,  which  is  distended  in  the  shape  of  a  barrel.  In  such  cases 


DISEASES  OF  THE   UTERUS.  415 

the  treatment  must  begin  by  gradual  dilatation  of  the  cervical  canal 
(p.  154).  If  the  os  is  so  small  that  not  even  a  common  uterine  sound 
can  enter,  it  is  necessary  first  to  make  a  little  nick  with  a  knife. 

In  chronic  endometritis  of  gonorrheal  origin  the  treatment  is  sim- 
ilar to  that  in  the  later  stage  of  the  acute  (p.  405). 

In  cases  that  had  resisted  all  other  treatment  the  writer  has  obtained 
a  cure  by  cutting  off  the  whole  mucous  membrane  of  the  cervix,  and 
leaving  the  wound  to  heal  over  an  intra-uterine  glass  stem. 

Exfoliating  Endometritis. — Exfoliating  endometritis,  also  called  men- 
strual endometritis,  or  membranous  dysmenorrhea,  is  a  rare  variety  of 
eudometritis  that  presents  so  peculiar  features  that  we  are  obliged  to 
treat  it  separately.  It  forms  a  link  between  acute  and  chronic  endo- 
metritis in  so  far  as  it  is  an  acute  process  that  repeats  itself  every 
four  weeks. 

Pathological  Anatomy. — The  mucous  membrane  of  the  body  of 
the  womb  is  swollen  and  red.  It  is  thrown  off  in  shreds  an  inch  in 
diameter  or  even  as  one  piece  representing  a  cast  of  the  uterine  cavity 
with  an  inner  smooth  and  outer  rough  surface  and  three  openings 
corresponding  to  the  internal  os  and  the  apertures  of  the  Fallopian 
tubes. 

Microscopical  examination  shows  that  the  uterine  glands  are  un- 
changed, but  that  there  is  great  hyperplasia  of  the  cells  of  the  endo- 
metrium,  which  retain  their  normal  size,  but  are  packed  so  closely 
together  that  little  space  is  left  for  the  inter-cellular  substance. 

Etiology. — Exfoliating  eudometritis  is  a  form  of  chronic  endometri- 
tis. It  is  sometimes  allied  to  fibroids,  and  occurs  in  women  affected 
with  syphilis,  tuberculosis,  or  suffering  from  acute  phosphorus- 
poisoning. 

Symptoms. — The  disease  is  characterized  by  severe  pain  in  the 
pelvis  recurring  at  each  menstrual  period  and  followed  by  the  expul- 
sion of  the  above  described  parts  of  the  endometrium.  It  may  be 
found  at  any  age  during  menstrual  life.  Persons  affected  with  it 
may  become  pregnant,  and  are  liable  to  abortion,  but  may  even  give 
birth  to  children  and  then  again  be  affected  in  the  old  way. 

Diagnosis. — Exfoliating  endometritis  is,  as  we  have  said,  a  very  rare 
disease,  and  assertions  to  the  contrary  are  based  on  errors  of  diagnosis. 
A  chief  point  in  the  diagnosis  is  the  regularity  of  the  expulsion  of 
membranes,  but  even  that  may  be  simulated  for  some  time  by  regu- 
larly repeated  abortions.  The  microscope  alone  can  positively  settle 
the  diagnosis.  The  presence  of  villi  chorii  is  absolute  proof  that  the 
specimen  is  a  product  of  conception,  and  even  the  decidua  of  preg- 
nancy differs  from  that  of  menstruation  by  the  large  size  of  the  cells 
of  the  endometrium. 

In  extra-uterine  pregnancy  a  similar  expulsion  of  the  endometrium 
may  take  place.  In  order  to  avoid  errors  as  much  as  possible  the  pel- 


416  DISEASES  OF  WOMEN. 

vis  must  be  examined  most  carefully  for  a  tumor  that  might  be  the 
fetal  sac,  and  all  signs  of  pregnancy,  genital,  pelvic,  abdominal,  sto- 
machic, mammary,  cutaneous,  and  nervous,  looked  for. 

7}'eatment. — Spontaneous  cures  are  reported,  but,  as  a  rule,  the  inter- 
vention of  the  healing  art  is  solicited.  The  endometrium  should  be 
destroyed  so  as  to  give  a  chance  for  a  new  and  better  growth.  This 
is  done  by  the  curette  followed  by  the  application  of  tincture  of  iodine 
or  iodoform  pencils,  or  by  the  galvano-chemical  cauterization  accord- 
ing to  Apostoli's  method. 

2.  Chronic  Parenchymatous  Metritis. — Pathological  Anatomy. — 
The  size  and  weight  of  the  uterus  are  increased,  the  wall  is  thicker, 
the  cavity  larger,  and  the  tissue  harder.  Microscopical  examination 
shows  that  the  muscular  bundles  are  separated  by  much  broader  layers 
of  connective  tissue  than  in  the  normal  uterus.  The  walls  of  the 
arteries  in  the  muscular  tissue  of  the  uterus  are  thickened  and  par- 
tially changed  to  connective  tissue.  The  lymph-spaces  are  enlarged, 
and  the  peritoneal  covering  thickened.  If  the  case  is  due  to  subin- 
volution  after  childbirth  or  abortion,  the  muscular  fibers  are  found 
enlarged  and  abnormally  numerous  (hypertrophy  and  hyperplasia).1 

Etiology. — The  parenchymatous  metritis  may  arise  by  extension 
from  chronic  endometritis.  Frequent  attacks  of  acute  metritis  may 
finally  lead  to  the  chronic  form.  It  may  be  due  to  exposure  to  cold, 
especially  living  in  a  cold  climate  and  in  a  damp  basement. 

Too  frequent  coition  and  still  more  a  connection  that  is  interrupted 
without  ending  in  orgasm  and  the  normal  sensation  of  contact  with 
the  ejaculated  semen,  abortion,  subinvolution  after  childbirth,  and  too 
rapidly  recurring  pregnancies,  favor  its  development.  It  frequently 
accompanias  displacements, — especially  retroflexions, — fibroids,  and 
cancer  of  the  uterus,  as  well  as  ovarian  tumors. 

Symptoms. — As  a  rule,  the  patient  has  no  fever,  but  occasionally  a 
rise  of  temperature  up  to  102°  Fahrenheit  shows  an  acute  exacerbation 
in  the  chronic  condition.  She  has  an  unpleasant  bearing-down  sensa- 
tion, often  combined  with  pain  in  the  groins  and  backache.  Men- 
struation is  usually  more  or  less  painful.  Quite  often  the  patient 
feels  an  irritation  of  the  bladder,  compelling  her  to  empty  that  organ 
frequently,  although  the  composition  of  the  urine  is  normal.  Con- 
stipation is  very  common. 

Hysteria  is  not  found  oftener  than  in  other  women,  and  is,  there- 
fore, probably  independent  of  the  disease. 

Menorrhagia  and  leucorrhea  are  very  common.  Nervous  reflexes, 
such  as  swelling  of  the  breasts,  mastodynia,  and  intercostal  neuralgia, 
accompany  it  frequently. 

The  dilatation  and  growth  of  the  uterus  during  pregnancy  is  ac- 
companied by  pain,  and  is  often  interrupted  by  abortion. 

1  Welch  of  Baltimore,  quoted  by  A.  P.  Dudley,  N.  Y.,  Med.  Jour.,  Sept.  4,  1886. 


DISEASES  OF  THE   UTERUS.  417 

Some  patients  have,  in  the  middle  of  the  interval  between  two 
periods,  a  so-called  intermenstrual  pain,  much  like  that  occurring 
with  menstruation,  but  of  shorter  duration,  and  sometimes  accom- 
panied by  the  excretion  of  bloody  mucus. 

Vaginal  examination  reveals  the  enlargement  and  tenderness  of 
the  body  of  the  uterus,  and  often  a  thickened,  hard,  eroded,  and 
granular  vaginal  portion. 

In  nervous  and  anemic  persons  a  tumor  is  sometimes  felt  in  one 
of  the  edges  of  the  uterus  at  the  junction  of  the  neck  and  the  body. 
It  may  become  as  large  as  a  hen's  egg.  It  is  semiglobular,  of  the 
consistency  of  a  myoma,  and  sensitive  on  pressure.  It  is  only  con- 
gestive, is  formed  during  hemorrhage,  and  disappears  when  the  bleed- 
ing stops.  After  the  bleeding  follows  an  offensive  discharge  like 
lochia.  These  tumors  have  been  described  by  French  authors  under 
the  name  of  "tumeurs  fluxionnaires"  and  are  supposed  to  be  due  to 
metritis. 

Diagnosis. — Cancer  of  the  body  of  the  womb  causes  greater  hard- 
ness, forms  a  tumor  that  can  be  felt,  and  is  accompanied  by  a  thin, 
purulent,  malodorous  discharge.  By  means  of  the  sound  the  inner 
surface  of  the  womb  may  be  found  to  be  irregular  and  to  contain 
spots  where  the  tissue  is  unusually  soft. 

Prognosis: — Chronic  parenchymatous  metritis  does  not,  as  a  rule, 
threaten  the  patient's  life  unless  the  hemorrhages  should  be  profuse 
enough  to  undermine  her  constitution,  but  it  is  an  exceedingly  tedious 
disease,  sometimes  extending  over  many  years,  and  a  perfect  cure  is  rare, 
although  much  can  be  done  to  alleviate  the  sufferings  of  the  patient. 

Treatment. — In  order  to  avoid  needless  repetition  the  reader  is 
referred  to  what  has  just  been  said  about  chronic  endometritis,  which 
always  accompanies  the  parenchymatous  form.  Here  we  will  only 
add  measures  particularly  indicated  where  the  muscular  coat  of  the 
uterus  is  implicated. 

Among  internal  medicines,  a  long-continued  use  of  small  doses  of 
chloride  of  gold,  or  of  corrosive  sublimate  (p.  227)  may  succeed  here  as 
in  other  parts  of  the  body  in  reducing  the  abnormal  deposit  of  con- 
nective tissue. 

In  cases  of  subin volution,  Tait  praises  the  effect  of  chlorate  of 
potassium,  gr.  viiss,  t.  i.  d.,  given  in  a  medicine  with  a  fewr  drops  of 
dilute  hydrochloric  acid. 

Faradization  has  a  similar  effect  by  causing  muscular  contraction. 
The  bipolar  intra-uterine  method  (p.  229)  is  particularly  recom- 
mendable.  Apostoli  praises  the  primary  current. 

The  galvanic  current  (p.  229)  may  help  to  reduce  the  bulk  of  the 
uterus  by  electrolysis. 

Massage  (p.  190)  causes  absorption  by  mechanical  manipulations. 

Finally,  operative  interference  not  only  serves  to  remove  redundant 

27 


418 


DISEASES  OF   WOMEN. 


tissue  mechanically,  but  experience  has  shown  that  it  so  modifies  the 
nutrition  of  the  womb  that  that  organ  may  shrink  considerably  in 
the  course  of  several  months  following  the  operation.  If  the  cervix 
is  lacerated,  trachehrrhaphy  (p.  399)  should  be  performed.  If  it  is 
not  torn,  but  much  enlarged,  it  may  be  diminished  in  different  ways. 

1.  Gordon's  Method} — If  the  cervical  canal  is  so  large  that  it 
can  be  done  without  causing  stenosis,  a  wedge-shaped  piece  may  be 
cut  out,  having  the  base  at  the  os  and  the  apex  at  or  somewhat  beyond 
the  utero- vaginal  junction.     This  operation  is  performed  exactly  like 
trachelorrhaphy,  and  recommends  itself  by  its  safety  and  simplicity 
and  by  leaving  a  normal  vaginal  portion,  which  may  be  needed  for 
the  adaptation  of  a  pessary. 

2.  Hegar's  Method  consists  in  the  removal  of  the  whole  vaginal 
portion.     The  patient  being  in  dorsal  decubitus,  the  vaginal  portion 
is  exposed  by  means  of  a  single  Sims  speculum  (p.  145)  and  side 
retractors  (p.  211),  and  the  uterus  pushed  and  pulled  down.     The 
cervical  portion  is   split   open   with    scissors   on   both  sides  up  to 
the  vaginal  vault.     Each   lip  is  seized   with  a  volsella  or  bullet- 
forceps  and  cut  off  with  scissors  bent  at  right  angles.     In  dealing 
with  the  anterior  lip  the  operator  must  take  care  not  to  go  beyond 
the   boundary-line   of  the   bladder,  which    may   be   ascertained    by 
means  of  a  metal  catheter.     Next,  the  mucous  membrane  of  the 
cervical  canal  is  united  by  a  row  of  sutures  to  that  of  the  vagina, 
comprising  part  of  the  cut  surface,  but  skipping  that  part  which  is 
farthest  away  from  the  mucous  membranes  (Fig.  234).     Sometimes  it 

FIG.  234. 


Hegar's  Amputation  of  the  Cervical  Portion  :  a,  two  sutures  on  each  side  do  not  enter  the  cer- 
vical canal ;  b,  all  sutures  are  passed  from  the  vaginal  to  the  cervical  mucous  membrane. 
In  both  cases  a  portion  of  the  cut  surface  is  skipped  in  inserting  the  sutures. 

is  better  only  to  do  this  in  the  middle,  and  to  unite  the  vaginal  mucous 
membrane  in  front  and  behind  at  the  sides-     This  is  done  with  rather 
1  S.  C.  Gordon  of  Portland,  Me.,  Amer.  Jour.  Obst.,  1884,  vol.  xvii.  p.  1205. 


DISEASES  OF  THE   UTERUS. 
FIG.  235. 


419 


Simon's  Coue-mantle-shaped  Excision  of  the  Vaginal  Portion :  a,  sutures  inserted  ;  b,  sutures 
tied.    (There  ought  to  be  one  or  two  on  each  lateral  incision). 

strong,  curved,  round,  crescent-ground,  or  trocar-pointed  needles  or 
the  fishhook-shaped  needles  (Fig.  184, /,  g,  and  E),  held  in  a  needle- 
holder.1 

FIG.  236. 


A  B  C 

Schroeder's  Single-flap  Excision  of  the  Vaginal  Portion :  A,  excision  made,  sutures  placed 
on  anterior  lip  and  tied  on  posterior;  1  and  2,  lateral  sutures.  B,  longitudinal  section 
through  cervix  ;  d  e,  transverse  incision  ;  /  e,  longitudinal  incision  joining  the  first  ana 
severing  the  mucous  membrane  and  part  of  the  muscular  tissue  from  the  cervix :  b  c, 
course  of  a  suture  ;  g,  ovula  of  Naboth.  C,  longitudinal  section  after  the  sutures  are  tied. 

3.  Simon's   Method,  the   so-called    cone-mantle-shaped   excision. — 
After  having  made  the  two  lateral  incisions  a  wedge-shaped  piece  is 

1  I  have  had  some  especially  made  by  Reynders  &  Co.,  corner  Fourth  avenue  and 
Twenty-third  street,  New  York. 


420  DISEASES  OF  WOMEN. 

cut  out  with  a  knife  of  the  whole  width  of  each  lip  from  side  to  side. 
Next,  the  two  flaps  of  each  lip  are  united  by  sutures,  and,  finally,  the 
two  lateral  incisions  are  similarly  closed  (Fig.  235). 

This  method  is  especially  indicated  when  the  cervix  is  very  thick 
and  hard  and  the  mucous  membrane  of  the  cervical  canal  healthy. 

4.  Schroeder's  Method. — The  same  lateral  incisions  as  in  the  other 
methods  are  used,  but  then  the  whole  mucous  membrane  of  each  lip 
with  part  of  the  muscular  tissue  is  cut  away.  For  this  purpose  a 
transverse  incision  is  made  through  the  mucous  membrane  of  the  cer- 
vix at  the  base  of  each  lip,  and  then  a  wedge-shaped  piece  is  cut  off 
from  the  os  to  the  first  incision.  Each  of  the  lips  is  folded  trans- 
versely, and  the  lower  end  of  the  cut  surface  united  to  the  upper. 
Finally,  the  side  incisions  are  closed  (Fig.  236).  This  method  is 
more  difficult  to  perform,  but  is  preferable  when  the  cervical  mem- 
brane is  in  a  bad  condition. 

The  removal  by  means  of  the  galvano-caustic  snare  is  less  appro- 
priate than  the  cutting  operations,  since  it  necessitates  the  healing  of 
the  wound  by  granulation  and  may  lead  to  stenosis  of  the  cervical 
canal. 

If  there  is  leucorrhea,  menorrhagia,  or  metrorrhagia,  it  is  proper 
to  combine  curetting  with  the  amputation. 

In  dangerous  hemorrhage  salpingo-odphorectomy  may  be  performed, 
and  if  that  does  not  suffice  to  arrest  the  loss  of  blood,  the  uterus  may 
have  to  be  removed  by  vaginal  hysterectomy. 


CHAPTER  V. 
CLOSURE  OF  THE  UTERUS  (ACQUIRED  ATRESIA). 

IN  the  description  of  malformations  we  have  seen  that  atresia  of 
the  uterus  may  be  congenital  (p.  391),  but  the  uterus  may  also  become 
closed  later  in  life — acquired  atresia. 

Although  not  so  rare  as  the  congenita.1  form,  the  acquired  is  still 
a  rare  affection. 

The  closure  is  most  common  at  the  external  os,  after  that  at  the 
internal  os,  but  more  or  less  of  the  whole  cervical  canal  may  be  closed. 

Etiology. — This  condition  may  be  brought  about  by  adhesions 
forming  after  childbirth  or  abortion,  cauterization  with  strong  acids 
or  nitrate  of  silver,  the  red-hot  iron,  or  the  galvano-caustic  apparatus 
(p.  235).  Ulceration  of  the  cervix,  diphtheria,  small-pox,  and  scarlet 
fever  may  lead  to  it.  Sometimes  it  is  simply  due  to  old  age,,  and  is 
especially  found  in  old  women  suffering  from  prolapse  of  the  uterus. 

Symptoms. — In  menstruating  women  the  acquired  closure  gives 
rise  to  symptoms  similar  to  those  of  the  congenital  closure,  such  as 


DISEASES  OF  THE   UTERUS.  421 

amenorrhea,  abdominal  pain,  menstrual  molimina,  and  swelling  of 
the  uterus  in  consequence  of  accumulation  of  blood  (hematometra), 
mucus  (hydrometra),  or  pus  (pyometra).  If  the  contents  of  the  uterus 
become  decomposed  and  gases  are  formed,  the  condition  is  called  phy- 
sometra.  Under  these  circumstances  the  percussion  sound  becomes 
tympanitic,  whereas  otherwise  it  is  dull. 

After  the  menopause  the  atresia  hardly  gives  rise  to  any  symptoms, 
unless  it  is  complicated  with  some  other  disease  of  the  womb,  espe- 
cially cancer  or  fibroma. 

The  size  of  the  womb  in  hydrometra  hardly  surpasses  that  of  a 
fist.  The  walls  are  distended  and  sometimes  thinner  than  in  the  nor- 
mal condition.  If  the  closure  is  at  the  external  os,  the  cervix  and 
the  body  form  together  one  globular  tumor. 

The  course  is  chronic.  Sometimes  the  disease,  especially  in  physo- 
metra,  terminates  spontaneously,  the  obstruction  in  the  cervix  giving 
way  and  the  gas  escaping. 

Treatment. — The  cervix  should  be  perforated  with  a  curved  trocar 
and  then  dilated.  The  uterine  cavity  should  be  washed  out  with  an 
antiseptic  fluid,  and  packed  with  iodoform  gauze  (p.  180).  In  regard 
to  the  dangers  of  the  operation  the  reader  is  referred  to  what  has 
been  said  in  speaking  of  atresia  in  other  parts  of  the  genital  canal 
(p.  327). 


CHAPTER    VI. 
STENOSIS  OF  THE  CERVIX. 

STENOSIS,  or  narrowness,  of  the  cervical  canal  is  somewhat  similar 
to  atresia,  but  the  difference  is  that  the  cervical  canal  is  open,  although 
the  caliber  is  too  small.  Like  atresia  it  may  be  congenital  or  acquired. 
It  is  often  combined  with  a  conical  cervix,  which  may  be  hyper- 
trophic,  of  normal  dimensions,  or  atrophic.  It  accompanies  also  dis- 
placements, especially  anteflexion. 

It  is  most  common  at  the  external  os,  which  forms  a  round  open- 
ing, sometimes  so  narrow  that  it  does  not  even  admit  the  common 
uterine  sound  (pinhole  os).  Less  frequently  it  is  found  at  the  inter- 
nal os.  Sometimes  the  whole  cervical  canal  from  end  to  end  takes 
part  in  the  stenosis,  but  in  other  cases  it  is,  on  the  contrary,  dilated 
between  the  two  narrow  openings  so  as  to  form  a  barrel-shaped  cavity. 

The  etiology  of  the  acquired  form  is  identical  with  that  of  atresia. 

Symptoms. — If  the  menstrual  blood  is  secreted  in  larger  amount 
than  what  can  pass  in  the  same  time  through  the  narrow  cervix,  the 
patient  has  pain  (obstructive  dysmenorrhea).  Often  the  blood  coagu- 
lates, and  the  clots  are  expelled  with  painful  cramps.  Also  mucus 


422  DISEASES  OF  WOMEN. 

may  stagnate  in  the  cervix  or  the  body  and  give  rise  to  bearing-down 
pain,  relieved  from  time  to  time  by  the  expulsion  of  the  accumulated 
fluid.  Sometimes  all  the  symptoms  of  chronic  endometritis  and 
parenchymatous  metritis  (pp.  409  and  416)  are  developed. 

Some  women  are,  however,  in  excellent  health  in  spite  of  their 
stenosis,  and  they  consult  us  only  on  account  of  sterility.  Although 
pregnancy  may  take  place  when  there  is  only  the  smallest  opening 
admitting  the  spermatozoids,  it  is  indisputable  that  a  narrow  cervical 
canal  is  a  great  impediment  to  conception. 

Diagnosis. — The  stenosis  of  the  external  os  can  be  felt  by  a  prac- 
tised finger  and  is  seen  by  means  of  the  speculum.  That  of  the 
internal  os  can  only  be  inferred  from  the  difficulty  with  which  the 
sound  passes.  The  beginner  must,  therefore,  be  on  his  guard,  as  he 
will  find  many  cases  of  stenosis  of  the  internal  os,  which  in  my 
experience  is  by  no  means  common.  The  normal  bore  is  only  \  inch 
(p.  49),  and  it  is  tight  enough  to  be  distinctly  felt  as  a  yielding 
obstruction,  when  the  knob  of  the  uterine  sound  passes  it.  Before 
diagnosticating  a  stenosis  of  it,  the  physician  must  make  sure  that  the 
end  of  the  sound  is  not  caught  between  the  folds  of  the  plicae 
palmatse  or  arrested  by  a  flexion.  For  this  purpose  it  must  be  intro- 
duced in  all  directions  and  with  dhTerent  degrees  of  curvature.  The 
best  proof  that  a  stenosis  really  exists  is  that  the  common  sound  is 
arrested  while  a  thinner  probe  passes. 

Treatment.- — Stenosis  used  to  be  treated  with  incision,  either  bilat- 
erally or  in  the  median  line  of  the  posterior  lip.  The  cervical  por- 
tion was  split  open  up  to  the  vaginal  junction  with  Kilchenmeister's 
scissors  (Fig.  237),  that  have  a  blunt  and  longer  blade  for  entering 

FIG.  237. 


Kiichenmeister's  Scissors. 


the  cervix  and  a  shorter  blade  ending  in  a  sharp  hook,  which  prevents 
the  scissors  from  sliding.  Besides,  the  incision  was  carried  more  or 
less  up  to  or  through  the  internal  os  with  Sims's  uterine  knife.  For 
cutting  the  internal  os  and  more  or  less  of  the  whole  cervix  Simpson's 


DISEASES  OF  THE   UTERUS.  423 

metrotome  (Fig.  238)  was  used,  a  sheathed  knife,  the  excursion  of 
which  is  regulated  by  a  screw,  and  which  cuts  in  one  direction  at  a 
time,  or  Greenhalgh's  metrotome,  that  cuts  both  sides  at  the  same  time. 
When  it  was  found  that  this  deep  cutting  not  infrequently  was  accom- 
panied by  dangerous  or  fatal  hemorrhage  or  by  not  less  dangerous 

FIG.  238. 


Simpson's  Metrotome. 

and  fatal  pelvic  septic  inflammation,  superficial  trachelotomy  was  sub- 
stituted.1 Cutting  for  stenosis  has  in  a  great  measure  been  replaced 
by  dilatation.  I  make  only  a  very  small  nick  at  the  external  os 
if  it  is  necessary  for  the  introduction  of  the  sound.  I  also  cut  out 
a  wedge-shaped  piece  of  the  cervix  if  the  os  besides  being  too  nar- 
row is  situated  exceutrically.  There  is  no  hemorrhage,  and  inflam- 
mation is  avoided  by  the  use  of  antiseptic  precautions  (p.  199). 

In  most  other  cases  I  only  use  dilatation  with  blunt  conical  and 
diverging  instruments  (p.  155),  which  is  much  safer  than  any  degree 
of  incision  or  the  use  of  tents.  I  have,  indeed,  never  seen  any  trou- 
ble arise  from  rapid  dilatation.  In  most  cases  1  treat  the  patient  in 
the  office  twice  a  week.  I  use  first  the  lower  numbers  of  Hanks's 
dilators,  and  then  my  own  diverging  dilator  up  to  one-half  inch  ex- 
pansion. I  never  go  farther  in  one  sitting  than  that  the  patient  can 
stand  the  pain  without  an  anesthetic.  In  more  exceptional  cases  I 
operate  in  the  patient's  house,  etherize  her,  use  the  strictest  antiseptic 
precautions,  and  open  the  dilator  to  full  expansion,  one  and  a  quarter 
inches  in  all  directions.  In  order  to  avoid  tearing  the  tissues  this  must 
be  done  very  slowly  and  gradually.  I  introduce  some  iodoform  into  the 
cervix,  and  cover  it  with  iodoform  gauze.  The  patient  is  kept  in  bed 
for  four  days.  A  glass  stem  (see  chapter  on  Flexions)  is  placed  in 
the  cervical  canal  while  it  is  contracting. 

The  canal  of  the  cervix  may  also  be  enlarged  by  means  of  electro- 
lysis. For  this  purpose  the  galvanic  current  is  to  be  used  with  the 
negative  pole  in  the  uterus,  the  positive  on  the  abdomen.  For  the 
latter  I  have  used  Engelmann's  electrode  (p.  231),  for  the  former 
Fry's,  which  has  six  nickel-plated  conical  tips,  ranging  from  11  to  25 
millimeters  in  circumference,  to  be  screwed  on  the  same  handle.  I 
have,  however,  not  found  any  advantage  in  the  electric  treatment  over 
the  mechanical. 

1  Peaslee,  Amer.  Journ.  Obst.,  1876,  vol.  ix.  p.  374. 


424  DISEASES  OF  WOMEN. 

CHAPTER    VII. 
ULCERS  OF  CERVIX. 

WE  have  mentioned,  in  treating  of  chronic  endometritis  (p.  408) 
that  the  term  ulcer  is  often  erroneously  applied  to  erosions  and  gran- 
ulations of  the  cervix.  But  the  cervix  may  be  the  seat  of  true 
ulceration — i.  e.  an  inflammatory  process  in  which  there  is  molecular 
loss  of  substance.  Such  ulcers  may  be  chancroids,  chancres,  tubercu- 
lar ulcers,  simple  ulcers,  or  corroding  ulcers. 

Chancroids  have  been  described  on  p.  291  and  chancres  on  p.  293, 
tuberculous  ulcers  p.  288  and  p.  363,  in  treating  of  the  diseases  of 
the  vulva  and  the  vagina. 

Simple  ulceration  takes  place  when  the  cervix  protrudes  through 
the  vulva,  be  it  in  consequence  of  hypertrophy  or  prolapse.  It  is  due 
to  friction  against  the  clothes.  There  is  a  flat  more  or  less  irregular 
loss  of  substance  surrounding  the  os,  or  what  seems  to  be  it,  if  the  case 
is  complicated  with  bilateral  laceration  of  the  cervix.  The  surround- 
ings have  a  blue  or  purple  color  and  are  harder  than  normal.  With 
proper  treatment  these  ulcers  heal  easily.  If  they  accompany  simple 
hypertrophy,  the  cervix  is  amputated  and  no  treatment  directed  to 
the  ulcer.  If  the  uterus  is  prolapsed,  it  should  be  replaced,  kept 
inside  the  vagina  by  a  perineal  bandage,  and  the  wound  covered 
with  a  piece  of  lint  smeared  with  the  ointment  of  iodoform  and 
balsam  of  Peru  (p.  178),  to  be  changed  morning  and  evening. 

Corroding  ulcer  looks  much  like  a  cancerous  ulcer,  and  is  destruc- 
tive in  character.  It  may  open  into  the  bladder,  but  on  microscopical 
examination  no  epithelial  elements  are  found.  It  seems  to  be  due  to 
senile  gangrene  induced  by  calcification  of  the  internal  iliac  artery.1 

The  diagnosis  can  only  be  made  by  means  of  the  microscope. 

The  treatment  is  the  same  as  for  cancer,  especially  total  extirpation 
before  the  formation  of  a  fistula. 


CHAPTER  VIII. 
HYPERTROPHY  OF  THE  UTERUS. 

AN  increased  size  of  the  uterus,  apart  from  neoplasms,  is  commonly 
due  to  subinvolution  or  chronic  metritis  (p.  416),  but  it  may  be  due 
to  simple  hypertrophy  independently  of  all  inflammatory  action.  The 
uterus  presents  abnormally  large  dimensions,  but  there  is  no  .change 
in  structure. 
This  hypertrophy  may  be  general  or  partial. 

1  John  Williams,  Trans.  Obst.  Soc.  of  London,  vol.  xxvii.,  reprint. 


DISEASES   OF  THE   UTERUS.  425 

General  hypertrophy  is  a  very  exceptional  condition.  Partial 
hypertrophy  has  rarely  its  seat  in  the  body.  As  a  rule,  then,  it  is  the 
cervix  that  is  the  affected  part.  We  distinguish  between  infravaginal 
and  supravaginal  hypertrophy.1 

A. — Infravaginal  hypertrophy  consists  in  an  increase  in  size  of  the 
vaginal  portion  of  the  uterus,  which,  as  a  rule,  takes  place  chiefly  or 
exclusively  from  above  downward,  resulting  in  an  elongated  cervix. 

This  hypertrophy  may  be  congenital  (p.  394)  or  acquired,  and  the 
condition  differs  somewhat  in  the  two  classes. 

The  congenitally  hypertrophied  cervix  is  only  elongated,  cylindrical, 
or  conical,  sometimes  trunk-shaped  in  consequence  of  the  greater 
development  of  one  of  the  lips,  mostly  the  posterior,  or  more  rarely 
club-shaped.  The  os  is  round,  of  normal  size,  or  too  narrow.  The 
elongation  may  be  slight  or  so  considerable  that  the  cervix  protrudes 
penis-like  from  the  vulva. 

In  the  acquired  form  of  hypertrophy  the  cervix  is  commonly  not 
only  elongated,  but  thickened,  and  it  is  frequently  thicker  near  the 
end  than  at  the  base,  forming  a  club-  or  cabbage-shaped  mass.  The 
os  is  large  and  forms  a  transverse  slit.  Very  often  the  cervix  has 
sustained  bilateral  laceration  (p.  396),  and  frequently  the  condition 
is  combined  with  prolapse  of  the  uterus,  but  in  these  two  classes  of 
cases  I  think  we  have  to  deal  with  chronic  metritis,  and  no  longer 
pure  hypertrophy.  The  acquired  form  is  exclusively  found  in  women 
who  have  borne  many  children. 

Etiology. — The  cause  of  the  congenital  hypertrophy  is  unknown. 
The  acquired  is  evidently  due  to  childbirth. 

Symptoms. — Sometimes  hypertrophy  of  the  cervical  portion  does 
not  give  rise  to  any  symptoms.  In  other  cases  the  patient  complains 
of  a  bearing-down  sensation  and  discomfort  in  walking  or  sitting 
down.  Sometimes  she  has  considerable  dysmenorrhea,  but  this  is 
probably  due  to  the  accompanying  stenosis  of  the  os  (p.  421). 
The  friction  against  the  vaginal  walls  may  cause  leucorrhea.  When 
the  cervix  protrudes  from  the  vulva  it  is  liable  to  become  ulcerated 
(p.  424).  If  the  hypertrophy  is  pronounced,  it  gives  rise  to  dys- 
pareunia,  the  male  member  meeting  with  an  obstruction,  which  is 
pushed  forward,  causing  discomfort  and  even  pain  to  the  female,  and 
sometimes  to  the  male  too.  The  semen,  being  ejaculated  into  the  deep 
pouch  formed  behind  the  cervix,  does  not  easily  enter  the  os,  and 
sterility  is,  therefore,  quite  common. 

Diagnosis. — The  diagnosis  is  easy.  By  vaginal  examination  the 
finger  may  be  carried  round  the  hypertrophied  cervix.  The  vaginal 

1  Schroeder  has  added  as  a  third  category  the  hypertrophy  of  what  he  calls  the 
intermediate  portion  ;  that  is,  that  part  of  the  cervix  that  is  bound  to  the  bladder  in 
front,  but  has  behind  the  deep  pouch  formed  by  the  posterior  fornix  of  the  vagina 
(p.  42);  from  a  practical  standpoint  this  variety  maybe  taken  together  with  the 
supravaginal. 


426  DISEASES  OF  WOMEN. 

vault  is  found  normal.  The  sound  may  enter  from  three  to  six 
inches,  and  yet  bimanual  examination  finds  the  fundus  uteri  at  its 
normal  place. 

Prognosis. — The  disease  is  chronic  and  has  no  tendency  to  retro- 
gression. In  virgins,  in  whom  the  vaginal  walls  and  the  uterus  have 
preserved  their  normal  resiliency,  an  elongated  cervix  does  not  find  room 
enough,  but  is  pushed  down  in  the  direction  of  the  outlet  and  serves 
as  a  lever  to  tip  the  uterus  backward  into  the  position  called  retro- 
version. 

Treatment. — Slight  degrees  of  elongation  may  successfully  be 
treated  with  dilatation  (p.  154),  which  enlarges  the  os  and  shortens 
the  canal.  In  more  pronounced  cases  the  redundant  tissue  must  be 
removed  by  amputation.  For  simple  elongation,  Hegar's  method 
(p.  418)  is  the  best;  for  hypertrophy  with  thickening  of  the  cervix 
Simon's  cone-mantle-shaped  excision  (p.  419)  recommends  itself. 
In  order  to  control  hemorrhage  it  is  a  good  plan  to  surround  the  base 
with  an. elastic  ligature.  If  feasible,  this  should  even  be  placed  above 
one  or  two  needles  perforating  the  cervical  portion  at  right  angles  and 
preventing  the  ligature  from  slipping,  or  sewed  to  the  cervix  with  a 
few  stitches.  The  common  6craseur  has  the  fault  of  having  a  tendency 
to  pull  in  neighboring  tissue  while  being  tightened,  by  which  the 
peritoneal  cavity  or  the  bladder  may  be  opened. 

The  galvano-cautery,  and  the  common  cautery  even  more,  expose 
to  stenosis  of  the  cervical  canal  (p.  421). 

B.  Supravaginal  hypertrophy  consists  in  the  increase,  especially 
elongation,  of  that  part  of  the  cervix  that  is  situated  above  the  utero- 
vaginal  junction. 

Pathological  Anatomy. — The  supravaginal  part  of  the  cervix  is  felt 
as  a  long  cylindrical  body,  somewhat  flattened  in  the  antero-posterior 
direction.  As  a  rule,  it  is  of  normal  circumference,  but  exceptionally 
it  may  either  be  thinner  or  thicker  than  normal.  The  dimensions  of 
the  infravaginal  portion  and  of  the  body  are  not  much  increased.  In 
growing  the  cervix  descends,  and  pulls  the  neighboring  organs  down 
with  it.  Thus  the  vaginal  fornix  sinks  down.  In  front  the  pouch 
formed  by  it  disappears  entirely,  while  behind  more  or  less  of  it  still 
remains.  The  vagina  becomes  inverted.  The  bladder  forms,  as  a 
rule,  a  swelling  in  front  of  the  hypertrophied  cervix  (eystocele) ; 
Douglas's  pouch  descends  with  it  behind,  and  sometimes  there  is  a 
rectocele,  but  in  many  cases  the  rectum  retains  its  place.  The  os  uteri 
forms  a  large  slit,  and  descends  to  or  beyond  the  rima  pudendi.  The 
interior  of  the  uterus  measures  from  six  to  ten  inches  in  depth,  the 
increase  coming  nearly  exclusively  from  the  elongation  of  the  upper 
part  of  the  cervix. 

Etiology. — This  condition  is  due  to  prolapse  of  the  vagina  (p.  340). 
The  body  of  the  womb  remaining  in  its  place,  and  the  cervix  being 


DISEASES  OF  THE   UTERUS.  427 

pulled  down,  it  is  drawn  out  like  a  rubber  tube.  At  the  same  time 
free  circulation  is  impeded,  the  blood  stagnates,  and  chronic  metritis 
sets  in,  with  formation  of  new  cells,  new  connective  tissue,  and  new 
muscle-fibers,  rendering  the  total  increase  in  bulk  possible. 

Those  conditions  which  promote  prolapse  of  the  vagina,  such  as 
laceration  of  the  vaginal  entrance,  frequent  childbirth,  too  early  get- 
ting up  after  delivery,  subinvolution,  occupations  that  keep  the  woman 
in  a  standing  position,  and  venereal  excesses,  lead  indirectly  to  hyper- 
trophy of  the  supra  vaginal  cervix. 

Symptoms. — The  symptoms  are  like  those  of  prolapse  of  the  vagina 
and  uterus,  combined  with  those  of  infra  vaginal  hypertrophy.  The 
patient  complains  of  bearing-down,  backache,  an  uncomfortable  sen- 
sation in  the  vagina,  especially  in  walking  and  sitting  down.  She  has 
often  dysmenorrhea.  She  has  frequent  desire  to  micturate,  and  finds 
it  often  difficult  to  empty  the  bladder.  She  is  constipated.  The  fric- 
tion in  the  vagina  produces  leucorrhea,  especially  in  the  posterior  pouch. 
Connection  is  rendered  unsatisfactory. 

That  part  of  the  vagina  that  is  turned  out  of  the  body  becomes 
horny,  like  epidermis.  The  enlarged  cervix  is  seen  and  felt,  while 
the  body  of  the  uterus  is  felt  above  of  nearly  normal  size,  often  ante- 
flexed,  and  the  infravaginal  portion  is  not  much  elongated,  if  at  all. 
Nearly  always  there  are  signs  of  bilateral  laceration  of  the  cervix,  and 
the  cervix  partakes  in  the  inversion,  so  that  the  lips  of  the  os  uteri  are 
situated  far  apart,  and  the  inverted  cervical  canal  appears  between 
them,  more  or  less  inflamed  or  even  ulcerated  (p.  424). 

Diagnosis. — A  polypus  and  an  inverted  uterus  have  no  opening  at 
the  lower  end.  In  the  infravaginal  hypertrophy  the  vaginal  vault  is 
normal.  The  chief  point  in  the  diagnosis  is  the  distinction  from  pro- 
lapse of  the  uterus,  with  which  the  supravaginal  hypertrophy  is  often 
confounded,  but  the  finger-shaped  mass  formed  by  the  cervix  is  easily 
felt  by  bimanual  palpation  with  one  finger  in  the  rectum ;  the  uterus 
is  felt  in  its  place ;  the  uterine  cavity  is  much  deeper ;  a  catheter  intro- 
duced into  the  bladder  is  not  felt  from  the  rectum,  the  uterus  inter- 
vening between  the  two  canals.  Frequently,  however,  the  hypertro- 
phy is  combined  with  prolapse. 

Prognosis. — No  spontaneous  cure  is  to  be  expected. 

Treatment. — In  the  lesser  degrees  the  uterus  may  be  pushed  up,  the 
body  becoming  strongly  anteverted,  and  much  comfort  may  be  afforded 
by  the  use  of  a  cup-shaped  supporter  attached  to  an  abdominal  belt. 
(See  Prolapse.)  If  this  plan  does  not  succeed,  recourse  must  be  had 
to  an  operation. 

1.  Hegar's  Method,  funnel-shaped  excision  (Fig.  239). — Dorsal 
posture.  The  cervical  portion  is  exposed  with  a'single  Sims  specu- 
lum and  lateral  retractors,  seized  with  a  volsella,  and  pulled  down. 
A  circular  incision  is  made  below  the  utero-vaginal  junction.  From 


428  DISEASES  OF  WOMEN. 

this  the  knife  is  carried  in  a  slanting  direction  upward  and  inward  to 
the  cervical  canal.    When  the  canal  has  been  opened  in  front  and  the 


FIG.  239. 


Hegar's  Funnel-shaped  Excision  of  Supra  vaginal  Cervix  (natural  size). 

hemorrhage  is  considerable,  a  suture  is  passed  immediately  under  the 
whole  wound  in  the  cervix,  and  so  as  to  comprise  the  mucous  mem- 
brane of  the  canal.  If  there  is  not  much  bleeding,  the  excision  is 
continued  from  the  sides  and  from  behind  with  knife  and  scissors. 
The  excised  piece  forms  a  cone,  the  length  of  which  above  the  utero- 
vaginal  junction  may  be  1^  to  1|  inches  or  more.  The  mucous  mem- 
brane of  the  cervix  is  sutured  all  around  to  that  of  the  vagina,  pass- 
ing the  sutures  with  small,  strongly  curved  needles  under  the  whole 
wound — a  procedure  that  is  very  difficult.  Some  prefer,  therefore,  to 
apply  the  thermo-cautery  as  soon  as  a  part  is  cut,  and  continue  alter- 
nating with  the  cutting  and  the  searing  instrument. 

2.  Schroeder's  Method  (Fig.  240)  is  still  more  radical.  A  circular 
incision  is  made  as  in  Hegar's.  If  vaginal  arteries  bleed,  the  hem- 
orrhage is  checked  with  ligatures  or  clamps.  Then  the  cervix  is 
separated  with  the  finger  and  blunt  instruments  in  front  and  behind. 
Next  it  is  pulled  over  to  one  side,  and  with  a  half-blunt  aneurism- 
needle  bent  to  the  side  (Fig.  269,  p.  487)  a  ligature  is  carried  around 
the  tissue  going  to  the  side  of  the  cervix  and  containing  the  blood- 
vessels. After  having  tied  the  ligature  tightly  and  cut  the  tissue 
between  the  ligature  and  the  cervix,  another  ligature  is  placed  above 
the  first.  The  other  side  is  treated  in  the  same  way. 

When  the  cervix  has  been  loosened  sufficiently  high  up,  the  ante- 
rior wall  is  cut  through  to  the  cervical  canal,  and  a  deep  suture  is 
carried  through  the  vaginal  wall,  the  parametral  connective  tissue,  and 


DISEASES  OF  THE   UTERUS. 


429 


the  severed  cervical  wall,  and  out  through  the  cervical  canal.     If 
necessary  to  check  hemorrhage,  several  such  deep  sutures  are  passed 


FIG.  240,  A. 


FIG.  240,  B. 


Schroeder's  Supravaginal  Amputation  of  Cervix. 

and  tied  before  the  posterior  wall  is  severed.  These  sutures  are  left 
long,  and  serve  to  keep  the  uterus  down.  When  the  posterior  part 
of  the  cervix  has  been  cut,  it  is  treated  in  the  same  way  as  the  ante- 
rior, thus  stitching  the  uterus  all  around  to  the  vagina. 

If  it  happens  that  the  peritoneal  cavity  is  opened,  the  rent  may  be 
closed  separately  with  silk  or  catgut,  or  comprised  in  the  sutures  fixing 
the  posterior  cervical  wall  to  the  vagina. 

The  vagina  being  much  larger  in  circumference  than  the  cervix,  it 
forms  folds  and  on  the  sides  two  gaps,  through  which  the  ligatures 
hang  down. 

3.  Kaltenbach's  Method  (Fig.  241). — After  emptying  the  bladder 
and  pushing  the  intestines  up  from  Douglas's  pouch,  the  cervix  is 
constricted  at  the  vaginal  entrance  with  an  elastic  ligature,  which  is 
stitched  to  the  inverted  vagina  in  front  and  behind,  or  the  uterine 
artery  is  secured  on  both  sides  (p.  182).  A  circular  incision  is  made, 
and  the  elongated  stipravaginal  cervix  is  easily  separated  from  the 
surrounding  tissue  with  knife  and  scissors,  and  even  partly  with  blunt 
instruments.  When  this  has  been  done  to  the  extent  deemed  neces- 
sary, sometimes  even  above  the  internal  os,  the  cervix  is  divided  with 
Kuchenmeister's  scissors  (p.  422)  into  an  anterior  and  a  posterior  half, 
a  transverse  incision  is  made  through  the  mucous  membrane  of  each 
half,  an  inch  from  the  top,  and  the  mucous  membrane  is  dissected  off, 


430  DISEASES  OF  WOMEN. 

except  at  the  top,  about  half  an  inch.     Then  the  remainder  of  the 
cervix  is  cut  off  transversely  at  the  base  of  the  flaps.     These  flaps 


Kaltenbach's  Supravaginal  Amputation  of  the  Cervix. 

are  stitched  to  the  vaginal  wall  with  three  or  four  deep  sutures,  com- 
prising some  of  the  muscular  part  of  the  stump.  If  we  go  too  near 
up  to  the  constrictor,  the  stumps  of  the  cervix  are  apt  to  retract 
beyond  it. 

Next,  a  triangular  piece  is  cut  out  on  both  sides  of  the  collar  formed 
by  the  receding  vagina,  and  a  couple  of  deep  sutures  are  passed  through 
the  edges  and  around  the  vessels  running  on  the  side  of  the  cervix, 
the  base  of  the  triangle  being  about  a  quarter  of  an  inch  from  the 
outermost  suture  on  either  side  and  the  top  at  the  constrictor.  This 
excision  allows  us  to  exercise  tighter  pressure  on  the  ligated  blood- 
vessels, and  affords  an  excellent  adaptation  of  the  fornix  to  the  stump. 

Finally,  the  contact  between  the  edges  of  the  two. mucous  mem- 
branes is  perfected  with  a  running  suture  of  catgut.  Then  the  con- 
strictor is  removed,  and  if  there  is  any  bleeding,  one  or  more  deep 
sutures  are  inserted  on  the  sides  of  the  stump. 

This  is  the  best  of  all  the  operations,  in  so  far  as  it  exposes  less  to 
hemorrhage  and  leaves  a  fine  stump. 

The  amputation  of  a  conical  piece  of  the  cervix,  as  in  Hegar's  opera- 
tion, may  also  be  accomplished  by  means  of  the  galvano-caustic  knife 
or  wire  (p.  235).  But  even  this  does  not  prevent  secondary  hemorrhage, 
and  is  liable  to  cause  stenosis  of  the  cervical  canal  (p.  421),  The 
patient  should,  therefore,  be  carefully  watched  during  the  healing 
process. 

Besides  primary  and  secondary  hemorrhage,  those  methods  of  the 


DISEASES  OF  THE   UTERUS.  431 

» 

supravaginal  amputation  which  leave  a  large  deep-seated,  more  or  leas 
anfractuous  wound  predispose  to  sepsis. 

4.  Vaginal    Hysterectomy. — These     drawbacks    are    avoided    by 
removing  the  whole  uterus,  which  may  be  done  from  the  vagina  or 
from  the  abdomen.     The  vaginal  operation  will  be  described  below 
under  Prolapse  of  tfie  Uterus. 

5.  Abdominal  Hysterectomy. — If  the  supravaginal  hypertrophy  of 
the  cervix  is  combined  with  such  an  hypertrophy  of  the  body  that 
the  removal  of  the  uterus  through  the  vagina  would  be  difficult,  it 
may  be  undertaken  through  the  abdominal  wall,  exactly  as  for  a 
myomatous  uterus.     (See  below,  under  Fibroid.) 


CHAPTER  IX. 

ACQUIRED  ATROPHY  ;   SUPERINVOLUTIOX. 

ATROPHY  of  the  uterus  may  be  congenital  or  acquired.  We  have 
described  the  congenital  form  above  (pp.  392,  393)  as  the  fetal,  the 
infantile,  and  the  pubescent  uterus. 

Acquired  atrophy  is  a  normal  condition  after  the  climacteric  (p. 
123), — senile  atrophy, — but  in  consequence  of  the  atrophy  closure  of 
the  cervical  canal,  especially  at  the  external  or  internal  os,  may  occur 
and  give  rise  to  hydro-  or  pyometra  (p.  421). 

The  writer  has  also  always  found  atrophy  of  the  uterus  in  removing 
this  organ  after  having  previously  performed  salpingo-oophorectomy 
on  the  same  patients. 

Pathological  Anatomy. — In  the  non-puerperal  form  the  uterus  is 
small,  the  vaginal  portion  disappears  sometimes  entirely,  so  that  the 
vagina  ends  in  a  narrow  funnel,  at  the  bottom  of  which  is  situated 
the  os.  The  tissue  is  hard,  its  arteries  often  calcareous,  and  it  some- 
times contains  foci  of  extravasated  blood.  The  cavity  of  the  uterus 
is  leas  deep  than  normal. 

The  puerperal  atrophy  differs  in  some  respects  from  the  non-puer- 
peral form.  The  walls  are  thin  and  often  very  soft,  and  the  uterine 
cavity  may  preserve  its  normal  depth. 

Etiology. — Puerperal  atrophy,  or  superin volution,  is  a  rare  disease. 
It  is,  perhaps,  oftener  connected  with  abortion  than  with  childbirth. 
It  is  caused  by  loss  of  blood,  protracted  lactation,  debilitating  dis- 
eases, such  as  scarlet  fever,  tuberculosis,  chlorosis,  syphilis,  diabetes, 
Bright's  disease,  and  exophthalmic  goiter. 

Atrophy  can  also  be  caused  mechanically  by  pressure  of  a  uterine 
fibroid  or  an  ovarian  cyst. 

It  may  be  brought  about  by  trachelorrhaphy,  amputation  of  cervix, 
or  oophorectomy. 


432  DISEASES  OF  WOMEN. 

Sometimes  salpingo-ob'phoritis  seems  to  be  the  cause  of  it,  and  it 
has  been  found  together  with  paraplegia. 

Symptoms. — Senile  atrophy  does  not  give  rise  to  symptoms  unless 
it  is  combined  with  atresia. 

Before  the  climacteric  atrophy  is  characterized  by  amenorrhea 
and  sterility.  Some  patients  complain  of  sacral  pain,  headache,  in- 
somnia, mental  depression,  anorexia,  indigestion,  and  general  weak- 
ness. Sometimes  the  uterine  cavity  measures  only  an  inch  or  an 
inch  and  a  half,  but  in  the  puerperal  form  the  sound  often  enters  to 
the  normal  depth  (pp.  49  and  152).  Its  knob  is  felt  with  unusual 
distinctness  through  the  abdominal  wall. 

Prognosis. — Puerperal  superinvolution  is  sometimes  only  transitory, 
whereas  the  other  forms  are  permanent. 

Treatment. — The  treatment  is  the  same  as  for  congenital  atrophy 
(p.  393).  

CHAPTER  X. 

GANGRENE. 

GANGRENE  of  the  uterus  may  occur  as  a  result  of  puerperal  infec- 
tion. An  inverted  uterus,  a  fibroid,  or  a  cancerous  tumor,  may  slough, 
and  in  this  way  a  spontaneous  cure  may  take  place. 

Treatment. — The  patient's  strength  should  be  kept  up  by  means  of 
quinine,  strong  alcoholic  drinks,  and  nourishing  food.  Locally,  fre- 
quent antiseptic  injections  should  be  used  in  the  vagina  (p.  172),  and 
even  in  the  interior  of  the  uterus. 


CHAPTER  XI. 
HYSTERALGIA. 

HYSTERALGIA,  or  neuralgia  of  the  uierus,  may  be  idiopathic  or 
symptomatic. 

Idiopathic  hysteralgia  is  a  rare  disease. 

Etiology. — It  is  most  common  at  the  menopause,  but  may  be  found 
in  young  girls,  especially  before  menstruation  is  well  established.  It 
is  also  found  in  anemic,  nervous,  and  hysterical  women.  Sometimes 
it  is  of  malarial  origin  or  due  to  rheumatism. 

Symptomatic  hysteralgia  may  accompany  any  of  the  organic  diseases 
of  the  womb,  especially  metritis  and  cancer. 

Symptoms. — Hysteralgia  is  characterized  by  sudden  attacks  of 
severe  pain  in  the  uterus,  often  radiating  to  the  sacral  region,  the 
iliac  fossa,  and  down  the  leg,  which  recur  with  regular  or  irregular 
intervals. 

Diagnosis. — The  chief  point  is  to  discover  whether  the  affection  is 


DISEASES   OF  THE   UTERUS.  433 

purely  nervous  or  whether  the  neuralgic  attacks  accompany  organic 
disease. 

Prognosis. — The  prognosis  is  favorable  if  the  neuralgia  is  not 
grafted  on  malignant  disease. 

Treatment. — During  the  neuralgic  attack  nothing  equals  in  cer- 
tainty and  swiftness  of  action  the  hypodermic  injection  of  morphine. 
In  the  intervals  the  underlying  disease,  if  any,  should  be  treated,  and 
the  idiopathic  form  should  be  treated,  according  to  the  etiology,  with 
tonics  (p.  225),  antiperiodics,  or  antirheumatic  medicines.  The  gal- 
vanic current,  with  the  positive  pole  in  the  vagina  or  uterus  (pp.  231, 
232),  is  very  effective,  and  so  is  the  high-tension  faradic  current  (p. 
230). 


CHAPTER  XII. 

DISPLACEMENTS. 

THE  normal  shape  and  position  of  the  uterus  have  been  discussed 
above  (p.  51),  and  we  have  seen  how  it  changes  position  according  to 
the  degree  of  fullness  or  emptiness  obtaining  in  the  bladder  and  the 
rectum  (p.  53).  Every  breath  makes  it  perform  a  see-saw  movement. 
During  inspiration  the  fundus  is  pushed  forward  and  downward, 
while  the  cervix  moves  upward  and  backward.  During  expiration  the 
opposite  movement  takes  place.  During  urination  and  defecation  it 
is  pushed  down ;  during  copulation  it  is  lifted  up.  It  is  therefore 
clear  that  the  uterus  is  an  unusually  mobile  organ.  But  certain  per- 
manent changes  and  deviations  from  the  normal  take  place  under 
certain  conditions,  and  constitute  the  so-called  displacements.  These 
are  anteversion,  antejlexion,  retroversion,  retroflexion,  lateroversion, 
laterqftexion,  anteposition,  retroposition,  lateroposition,  prolapsus,  ele- 
vation, inversion,  and  hernia. 

Anteposition,  retroposition,  and  lateroposition,  if  they  are  not  due 
to  pressure  from  a  neighboring  tumor,  are  developmental  abnormalities 
of  merely  anatomical  interest  (p.  394). 

A.'  Anteversion. 

Anteversiou  (Fig.  242)  is  that  position  of  the  uterus  in  which  the 
fundus  points  forward,  and  sometimes  downward,  to  the  symphysis 
pubis,  the  os  backward,  and  sometimes  upward,  toward  the  sacrum. 
The  uterine  canal  preserves  its  normal  direction  in  a  line  that  is 
straight  or  slightly  curved  forward  (p.  52). 

Pathological  Anatomy. — The  uterus  is  more  or  less  enlarged  and 
in  a  condition  of  chronic  metritis.  Sometimes  adhesions  are  found 

28 


434 


DISEASES  OF  WOMEN. 


between  the  fundus  and  the  peritoneum  or  signs  of  cellulitis  round 
the  cervix  ;  or  the  ovary  or  tube  may  be  found  adherent  to  the  anterior 
wall  of  the  pelvis.  Often  the  vaginal  portion  is  unusually  short. 


FIG.  242. 


Anteverted  Uterus  (Fritsch). 

Etiology. — Anteversion  is  due  to  inflammation  of  the  parenchyma 
of  the  womb,  in  consequence  of  which  the  organ  becomes  larger  and 
heavier  and  tips  down  in  the  erect  and  sitting  posture ;  or  to  inflam- 
mation of  the  pelvic  peritoneum  or  the  appendages,  in  consequence 
of  which  the  fundus  uteri  is  dragged  forward  and  downward. 

Anteversion  is  sometimes  due  to  subinvolution  after  childbirth  or 
abortion,  but  is  not  rare  in  virgins. 

Symptoms. — These  are  the  same  as  in  chronic  endometritis  and 
parenchymatous  metritis  (pp.409  and  416),  especially  frequent  mic- 
turition, dysmenorrhea,  menorrhagia,  leucorrhea,  and  sterility.  The 
frequency  of  micturition  is  probably  due  to  pressure  of  the  enlarged 
uterus,  just  as  we  commonly  find  it  in  pregnancy.  The  dysmenor- 
rhea may  be  mechanical,  the  exit  for  the  blood  being  less  free  when 
the  uterine  canal  is  horizontal  or  even  lies  higher  with  its  open  than 
with  its  closed  end  ;  or  it  may  be  explained  by  the  increased  sensitive- 
ness due  to  the  inflammation  of  the  uterus  or  its  surroundings.  The 
menorrhagia  and  leucorrhea  are  likewise  probably  due  partly  to  me- 


DISEASES  OF  THE   UTERUS. 


435 


chanical  interference  with  free  circulation  and  partly  to  the  structural 
changes  in  the  uterus. 

If  there  are  no  adhesions,  a  peculiar,  uncomfortable  feeling  is  pro- 
duced by  the  movements  of  the  enlarged  and  stiff  uterus. 

Diagnosis. — By  bimanual  examination  the  fundus  of  the  uterus  is 
found  tipped  forward,  the  anterior  surface  forms  a  straight  line  or 
nearly  so,  and  the  os  is  not  situated  centrally  in  the  pelvis,  within 
easy  reach,  but  points  backward  and  is  only  reached  with  difficulty. 

Prognosis. — Anteversion  does  not  threaten  life,  but  is  hard  to  cure, 
mechanical  disadvantages  increasing  the  troubles  inherent  in  the  sub- 
jacent inflammatory  conditions. 

Treatment. — The  treatment  is  directed  against  the  inflammation, 
or  is  intended  to  overcome  the  mechanical  disadvantage.  In  regard 
to  the  first,  the  reader  is  referred  to  what  has  been  said  above  (pp. 
412-415  and  417,  418).  The  remedies  especially  useful  are  the  hot 

douche,    glycerin    or    ichthyol    tampon, 
FIG.  243.  scarification,  electrolysis,  gold,  corrosive 

sublimate,  massage,  and  hemostatic  meas- 
ures (pp.  181,  182  and  227). 

The  uterus  may  be  lifted  up  by  means 

FIG.  244. 


Graily  Hewitt's  Antevereion  Pessary: 
a  6,  anterior  bow  resting  on  the  ante- 
rior wall  of  the  vagina ;  c  e,  upper 
end  pressing  on  the  anterior  surface 
of  the  uterus ;  d,  posterior  bow  going 
behind  cervix. 


Thomas's  Anteversion  Pessary :  A,  lower  end  rest- 
ing just  inside  the  vaginal  entrance ;  B,  upper 
end  to  be  introduced  in  the  posterior  pouch  of 
the  fornix ;  C,  anterior,  movable  bow,  which  is 
to  lift  the  uterus  through  the  anterior  pouch  of 
the  fornix. 


of  vaginal  pessaries — that  is,  supporters.  Those  most  used  for  this 
purpose  are  Graily  Hewitt's  cradle  pessary  (Fig.  243),  Thomas's  two 
kinds  (Figs.  244  and  245)  of  anteversion  pessaries,  Geh rung's  pes- 
sary (Fig.  246).  If  the  uterus  bends  over  these  instruments  and 
an  anteflexion  is  formed,  they  do,  however,  more  harm  than  good. 
There  is  a  soft-rubber  Vienna  pessaiy  consisting  of  a  thick  elas- 
tic ring  which  surrounds  the  cervix,  and  a  straight  piece  lying 
in  the  canal  of  the  vagina,  which  I  occasionally  have  found  very 
useful. 


436 


DISEASES  OF    WOMEN. 


General  Remarks  about  Pessaries. — Some  pessaries,  such  as  elastic 
rings,  work  by  pressing  exeeutrically  on  the  vaginal  walls ;  others,  a 
class  to  which  the  above-mentioned 
Thomas  pessary  (Fig.  244)  belongs,  Sto.  246. 

rest  against  the  muscles  and  fasciae  ,'"" "~    "*""  \ 

forming     the     vaginal     entrance; 
Gehrung's   pessary  and  Thomas's 

FIG.  245.  / 


Thomas's  Horseshoe-shaped 
Anteversion  Pessary. 


Gehrung's  Pessary. 


horseshoe  pessary  find  support  on  the  anterior  and  the  posterior 
vaginal  walls. 

In  the  choice  of  a  pessary  great  care  should  be  taken  never  to 
choose  a  larger  one  than  necessary.  If  it  is  made  of  some  hard 
material,  it  is  liable  to  erode,  and  even  to  burrow  deep  into  the  flesh 
and  perforate  the  rectum  or  the  bladder.  The  vagina  ought,  there- 
fore, to  be  inspected  three  or  four  days  after  the  introduction  of  a  pes- 
sary, in  order  to  make  sure  that  there  is  no  erosion,  and  later  the  exam- 
ination ought  to  be  repeated  at  least  once  every  two  months.  If  at 
any  time  it  is  found  that  the  vagina  becomes  excoriated,  the  pessary 
ought  to  be  left  out  for  a  week,  during  which  the  patient  should  use 
injections  with  carbolized  water. 

In  order  to  avoid  erosion  the  ring  forming  the  pessary  should  be 
rather  thick  and  perfectly  smooth. 

Soft  rubber,  and  in  some  women  even  hard  rubber,  emits  an 
unpleasant  odor  when  in  contact  with  vaginal  discharges.  This  may 
be  obviated  by  using  block-tin  for  the  construction  of  the  pessary, 
but  that  has  the  fault  of  being  heavy.  An  excellent  material  is 
aluminium. 

Pessaries  are  introduced  while  the  patient  occupies  the  dorsal  or 
left  lateral  position.  In  antedeviations  the  former  is  preferable,  in 
retrodeviations  the  latter.  The  uterus  ought,  as  a  rule,  to  be  replaced 
in  the  right  position  with  the  fingers  or  sound  before  introducing  the 
pessary,  just  as  fractures  are  set  before  the  splint  is  applied.  The  pes- 
sary, except  the  part  seized  by  the  physician,  should  be  smeared 
with  a  lubricant  (p.  140). 


DISEASES   OF  THE   UTERUS.  437 

Graily  Hewitt's  cradle  pessary  is  inserted  with  the  patient  on  her 
back.  First,  one  ring  is  introduced  inside  of  the  vaginal  entrance 
along  the  posterior  wall  of  the  vagina,  then  the  middle  part  is  pushed 
up  in  front,  and  finally  the  second  ring.  The  first  ring  is  placed 
round  the  cervix  ;  the  middle  part  presses  against  the  anterior  fornix 
of  the  vagina ;  and  the  second  ring  rests  on  the  anterior  vaginal  wall. 
In  removing  it  the  index-finger  is  hooked  into  the  lower  ring  and 
pulled  back.  Thus  this  ring  will  come  out  first,  rolling  over  the 
perineum,  then  the  middle  piece,  and  finally  the  upper  ring. 

Thomas's  ante  version  pessary  with  movable  front  bow  is  introduced 
closed  behind  the  cervix,  and  then  withdrawn  a  little,  so  as  to  allow 
one  to  separate  the  anterior  bow  from  tli«  rest  of  the  instrument  and 
push  it  in  front  of  the  cervix ;  finally,  the  whole  is  pushed  up  until 
both  bows  rest  on  the  vaginal  vault,  one  in  front  and  the  other  behind 
the  cervix.  (Compare  rules  for  introducing  Hodge's  pessary  under 
Retroflexion.) 

Thomas's  horseshoe-shaped  pessary  is  introduced  open ;  the  horse- 
shoe is  placed  against  the  anterior  surface  of  the  uterus,  and  the  lower 
bow  turned  forward  against  the  anterior  vaginal  wall.  In  withdraw- 
ing it  this  bow  is  seized,  when  the  remainder  of  the  instrument 
follows  easily. 

Gehrung's  pessary  is  placed  with  the  upper  horseshoe  turned  down 
on  a  table,  the  two  bows  uniting  the  horseshoes  pointing  toward  the 
doctor.  Next  he  seizes  the  nearest  bow  with  the  right  thumb  and 
index-finger,  pushes  the  opposite  bow  into  the  right  side  of  the  pelvis, 
then  the  bow  he  holds,  into  the  left  side,  and  finally  he  turns  the  whole 
pessary  in  the  vagina,  until  the  two  uniting  bows  rest  on  the  posterior 
wall  and  the  two  horseshoes  embrace  the  cervix  anteriorly.  In  with- 
drawing the  same  movements  are  gone  through  in  opposite  order. 

The  best-fitting  pessary  irritates  the  vagina  somewhat.  Whenever 
one  is  worn,  the  woman  must,  therefore,  at  least  once  a  day  use  an 
injection  of  a  pint  of  lukewarm  water,  to  which  may  be  added  a  tea- 
spoonful  of  borax  or  carbolic  acid,  in  order  to  keep  the  pessary  clean. 
She  should  also  be  instructed  to  remove  it  immediately  if  it  causes 
pain,  as  neglect  in  this  respect  may  cause  serious  pelvic  inflammation. 

An  elastic  abdominal  belt  may  give  comfort  by  taking  off  pressure 
from  above  and  steadying  a  large  mobile  uterus.  The  latter  object 
is  attained  still  better  by  an  abdominal  supporter  with  a  solid  hypo- 
gastric  pad,  such  as  Fitch's  (Fig.  166,  p.  191). 

Certain  operations  have  proved  useful  in  different  ways.  If  the 
cervix  is  thick,  Simon's  cone-mantle-shaped  excision  (p.  419)  may  be 
performed,  and  result  in  a  considerable  reduction  in  the  size  of  the 
body  of  the  uterus  (p.  418). 

Sims  folded  the  anterior  wall  of  the  vagina  transversely,  denuded 
the  edges  of  the  fold  just  in  front  of  the  cervix  and  an  inch  and  a 


438  DISEASES  OF  WOMEN. 

half  lower  down,  and  united  the  two  somewhat  crescent-shaped  sur- 
faces with  silver-wire  sutures  (p.  218). 

B.  Anteflexion. 

We  know  from  the  anatomical  part  (p.  52)  that  the  canal  of  the 
uterus  is  normally  straight  or  slightly  curved,  with  the  concavity  for- 
ward, or  slightly  S-shaped.  When  it  forms  a  more  decided  curve  or  an 
angle,  the  condition  is  abnormal,  and  is  called  anteflexiou  (Fig.  247). 

FIG.  247. 


Anteflexion  (Graily  Hewitt). 


Classification. — A  time-honored  division  of  anteflexion  is  that 
according  to  the  size  of  the  angle  between  the  cervix  and  body,  an 
obtuse  angle  constituting  the  first  degree,  a  right  angle  the  second, 
and  an  acute  angle  the  third.  A  better  classification,  because  of 
greater  practical  value  in  regard  to  treatment,  is  that  into  corporeal, 
in  which  the  body  of  the  womb  dips  too  far  forward  and  downward, 
while  the  cervix  has  the  normal  direction;  cervical,  in  which  the 
cervix  is  turned  forward ;  and  cervico-corporeal,  in  which  both  the 
body  and  the  neck  are  turned  forward ;  each  of  which  varieties  may 
again  be  reducible — that  is,  the  flexion  can  be  overcome  with  pressure 
of  the  fingers  or  by  the  introduction  of  a  sound ;  or  irreducible,'  when 
the  uterus  cannot  be  straightened.1 

1  T.  G.  Thomas,  Gynecol.  Trans.,  1888,  vol.  xiii.  p.  142 — a  paper  of  the  greatest 
value  to  anybody  who  undertakes  to  treat  anteflexion. 


DISEASES  OF  THE   UTERUS.  439 

Still  another  classification  is  that  which  distinguishes  a  congenital, 
or  rather  developmental,  form  from  an  acquired. 

Pathological  Anatomy. — The  bend  in  the  uterus  is,  as  a  rule,  situ- 
ated at  the  internal  os,  but  may  exceptionally  be  situated  higher  up 
in  the  body  or  lower  down  in  the  neck.  At  the  angle  is  often  found 
fatty  degeneration,  atrophy,  or  cicatricial  tissue.  The  uterus  is  often 
in  a  condition  of  chronic  metritis  (p.  416),  with  enlargement  of  the 
cavity.  Frequently  the  supravaginal  portion  is  elongated  (p.  426). 
In  the  developmental  form  the  anterior  vaginal  wall  is  short,  the 
cervical  portion  elongated  and  coniform,  with  a  small  os,  which  some- 
times is  situated  on  the  anterior  surface  instead  of  the  end  of  the 
cervix.  Sometimes  the  sacro-uterine  ligaments  are  swollen  or  short- 
ened. The  fundus  may  be  bound  with  adhesions  to  the  anterior  wrall 
of  the  pelvis,  or  similar  adhesions  implicate  the  ovaries  and  tubes. 

Sometimes  the  anteflexed  uterus  is  at  the  same  time  anteverted  or 
retro  verted. 

Etiology. — The  uterus  undergoes  a  great  development  from  the 
time  of  approaching  puberty  until  the  woman  is  full-grown,  say  be- 
tween the  ages  of  twelve  and  twenty  years  (p.  33).  During  this  fime 
it  is  more  liable  to  become  anteflexed  than  after  it  is  fully  formed. 
The  pressure  of  corsets  (p.  129)  and  the  weight  of  heavy  skirts  are  apt 
to  force  the  body  down.  An  accumulation  of  hard  scybala  in  the 
rectum  presses  the  cervix  forward  and  impairs  the  general  health 
(p.  128),  which  again  weakens  the  tissue  of  the  womb.  The  latter 
condition  is  also  a  consequence  of  lack  of  substantial  food  (p.  128). 
Masturbation  (p.  297)  causes  hyperemia,  and  thus  furthers  anteflexion. 
Exposure  during  menstruation  (p.  129)  may  have  a  similar  effect. 

The  acquired  form  is  mostly  due  to  inflammation  of  the  uterus  or 
its  surroundings:  metritis,  which  makes  the  uterus  heavier;  cellulitis 
around  the  utero-sacral  ligaments,  which  pulls  the  angle  between  cor- 
pus and  cervix  upward  and  backward  ;  and  perimetritis  or  inflamma- 
tion of  the  appendages,  resulting  in  adhesions  pulling  the  fundus 
forward  and  downward.  These  inflammations  are  again  caused  by 
gonorrheal  or  puerperal  infection,  or  are  simply  due  to  colds ;  that  of 
the  sacro-uterine  ligaments  may  also  originate  in  irritation  caused  by 
the  passage  of  hard  scybala. 

Anteflexion  may  also  be  due  to  subinvolution  following  childbirth 
or  abortion ;  pressure  from  an  abdominal  tumor ;  the  presence  of  a 
growth,  especially  a  fibroid,  in  the  wall  of  the  corpus ;  and  softening 
of  the  uterine  parenchyma  in  consequence  of  wasting  diseases  or 
insufficient  nutrition. 

Symptoms. — Sometimes  women  with  pronounced  anteflexion  enjoy 
perfect  health,  and  the  only  thing  that  brings  them  to  the  physician 
is  sterility.  The  symptom  next  in  frequency  is  dysmenorrhea  (p. 
242),  which  may  be  due  to  obstruction  at  the  angle  with  formation 


440  DISEASES  OF  WOMEN. 

of  clots,  and  which,  perhaps,  in  other  cases  is  rather  attributable  to 
the  concomitant  inflammation,  the  menstrual  congestion  pressing  on 
the  tender  inflamed  tissue  of  the  womb  or  the  surrounding  parts. 
Young  girls  affected  with  the  developmental  form  may  also  suffer 
from  amenorrhea.  The  patient  often  complains  of  pelvic  pain  or 
diverse  reflex  disorders,  especially  pain  in  the  epigastrium,  with  dys- 
pepsia, intercostal  neuralgia,  headache,  backache,  asthenopia  (p.  409), 
etc.  She  has  often  leucorrhea.  She  is  often  inconvenienced  by  fre- 
quent micturition,  as  in  anteversion.  Anteflexion  predisposes  to 
abortion  and  to  hyperemesis  during  pregnancy. 

Diagnosis. — When  the  cervix  is  turned  forward  the  observer  might 
think  of  retroversion,  but  by  bimanual  examination  the  whole  shape 
of  the  womb,  and  especially  the  presence  of  the  fundus  at  the  ante- 
rior vaginal  fornix.  is  distinctly  felt.  If  in  stout  women  there  is  any 
doubt,  the  flexion  is  felt  still  better  by  placing  the  patient  in  Sims's 
position,  when  the  fundus  tips  forward  on  the  examining  finger.  The 
direction  of  the  canal  can  be  made  out  with  the  sound  or  probe 
(p.  152,  153). 

In  anteversion  the  os  points  backward  and  the  uterus  is  straight. 

The  presence  of  a  fibroid  in  the  anterior  wall  can  be  made  out  by 
introducing  a  sound,  which  will  enter  with  the  normal  curvature 
turned  forward,  and  feeling  the  tumor  between  the  sound  and  the 
vaginal  vault. 

Inflammation  and  shortening  of  the  sacro-uterine  ligaments  are 
characterized  by  the  high  position  of  the  vaginal  portion,  its  approxi- 
mation to  the  posterior  wall  of  the  pelvis,  its  forward  direction,  and 
the  diminished  or  suspended  mobility  of  the  uterus.  By  direct  pal- 
pation through  the  anus  one  or  both  folds  are  felt  swollen,  tender, 
or  hardened. 

Prognosis. — Less  pronounced  cases  are  much  benefited  by  treat- 
ment, and  often  cured,  especially  if  pregnancy  occurs,  which  is  often 
the  case.  Otherwise  there  is  tendency  to  relapse.  I  have  never  seen 
an  anteflexed  womb  become  straight,  but  the  symptoms  may  disappear 
and  the  patient  feel  well.  Irreducible  cases  have  to  be  treated  with 
operations  which  are  neither  free  from  danger  nor  sure  to  cure. 

Treatment. — The  treatment  is  partly  directed  against  the  inflamma- 
tion and  partly  it  is  mechanic.  The  patient  should  avoid  violent 
exercise  and  tight  lacing.  Her  skirts  should  be  suspended  by  means 
of  braces  from  the  shoulders.  Her  bowels  should  be  kept  open,  and 
a  tonic  treatment  followed  in  regard  to  food,  regimen,  and  medicines 
(p.  225). 

Congestion  and  inflammation  are  combated  with  hot  vaginal 
douches  (p.  171),  glycerin  or  ichthyol  tampons  (p.  178),  painting 
with  iodine  (p.  170),  and  scarification  (p.  186).  When  there  is  a 
tendency  to  hemorrhage,  curetting  (p.  176),  with  or  without  intra- 


DISEASES  OF  THE    UTERUS. 


441 


uterine  packing  with  iodoform  gauze  (p.  180),  does  a  great  amount 
of  good. 

The  sound  is  introduced  with  a  curvature  nearly  as  strong  as  that 
of  the  uterine  canal,  withdrawn,  straightened,  and  reintroduced. 
Soon,  if  not  in  the  first  sitting,  it  is  turned  with  the  concavity  back- 
ward, establishing  a  transient  retroflexion.  The  uterus  may  also  be 
stretched  bi manually  by  pushing  the  cervix  back  with  a  finger  in  the 
vagina,  and  pressing,  with  the  other  hand,  on  the  fund  us  through  the 
abdominal  wall.  If  the  patient  is  treated  at  home,  she  should  con- 
tinue in  the  dorsal  posture  for  an  hour,  keeping  up  pressure  on  the 
replaced  fundus  by  means  of  a  hard-rolled  towel  applied  over  the 
symphysis. 

Mild  or  complete  dilatation  with  Hanks's  and  my  dilators  (p.  155) 
not  only  overcomes  the  obstruction  in  the  canal  at  the  angle,  but 
straightens  the  whole  uterus.  By  the  insertion  of  a  glass  stem  while  it 
recontracts,  a  better  shape  may  be  obtained.  Permanent  dilatation 
is  secured  by  Outerbridge's  instrument  (p.  184). 

Some  praise  electrolysis  (p.  423). 

An    abdominal    belt   or    supporter  FIG.  248. 

(p.  190)  may  serve  to  take  off  pres- 
sure from  above. 

The  same  pessaries  as  for  antever- 
sion  may  be  used  for  anteflexion.  Per- 
sonally, I  have  almost  abandoned 
them,  and  find  that  I  obtain  better 
results  without  them. 

If  a  vaginal  pessary  may  irritate 
and  cause  inflammation,  the  intra- 
uterine  stem  (Fig.  248)  is  still  more 
dangerous.1  It  should  be  of  glass, 
and  half  an  inch  shorter  than  the 
cavity  of  the  uterus.  It  may  be 
solid  or  hollow,  straight  or  slightly 
bent.  In  order  to  hold  it  in  place, 
it  is  sometimes  combined  with  a  vagi- 
nal pessary  having  a  little  cup  into 

which  the  plate  of  the  stem  fits.  It  should  have  a  string  attached 
to  it.  It  is  introduced  with  the  fingers  or  a  dressing  forceps  (p.  150) 
through  a  Sims  speculum. 

Irreducible  cases  may  be  treated  by  one  of  the  following  ope- 
rations : 

1.  Sims' s  Discission  of  the  Posterior  Lip. — The  patient  is  in  Sims's 
position ;  the  cervix  is  exposed  with  his  speculum ;  the  posterior  lip 

1  Garrigues,  "  Case  Illustrating  the  Danger  of  Stem  Pessaries,"  Amer.  Jour.  Obst., 
1879,  vol.  xii.  p.  756. 


Intra-uterine    Stem  and   Retroflexion- 
Pessary  with  Cup  (T.  G.  Thomas). 


442  DISEASES  OF  WOMEN, 

is  cut  in  the  median  line  up  to  the  vaginal  junction  with  Kiichen- 
meister's  scissors ;  and  a  second  incision  carried  in  a  straight  line  from 
the  internal  os  to  the  upper  end  of  the  first  incision.  The  wound  is 
packed  with  iodoform  gauze,  and  the  vagina  tamponed  as  long  as  there 
is  any  danger  of  hemorrhage.  The  dressing  is  changed  daily.  The 
patient  should  stay  in  bed  until  the  wound  is  healed ;  that  is,  from  two  to 
four  weeks.  When  granulation  is  established  an  intra-uterine  stem  may 
be  introduced.  The  granulating  wound  is  often  slow  to  heal,  and  may 
give  rise  to  a  troublesome  discharge  resisting  astringent  applications. 

2.  Amputation  of  the  Cervix. — If  there  is  considerable  flexion  of 
the  cervix  with  elongation,  the  cervical  portion  is  removed  by  Hegar's 
method  (p.  418). 

3.  Dudley's  Operation. — Recently !  a  plastic  operation  has  been  pro- 
posed with  a  view  to  straighten  the  anteflexed  uterus.     The  patient 
occupies  the  left  lateral  position.     The  cervical  canal  having  been 
exposed  with  Sims's  speculum,  and  a  little  dilated,  and  the  uterus 
curetted  and  disinfected,  the  posterior  lip  of  the  cervix  is  divided 
with  scissors  considerably  past  the  utero-vaginal  junction.     The  cut 
surfaces  are  separated  with  tenacula,  and  the  incision  somewhat  deep- 
ened, especially  on  the  side  of  the  cervical  canal.     On  each  side  the 
surface  thus  incised  is  now  folded  upon  itself  from  before  backward, 
and  secured  by  silkworm-gut  sutures.     Thereby  the  os  extern  urn  is 
carried  directly  back  to  the  angle  of  the  incision.     Then  the  anterior 
lip  of  the  cervix  is  caught  with  a  tenaculum  and  partially  removed, 
the  section  extending  to  the  external  os,  but  not  into  the  canal.    This 
cut  surface  is  folded  upon  itself  from  side  to  side  and  secured  with 
deep  sutures.     Normal  or  sclerotic  uterine  tissue  is  too  stiff  for  such 
folding  as  prescribed.     The  possibility  of  performing  this  operation 
seems,  therefore,  limited  to  cases  in  which  the  cervix  is  abnormally 
soft. 

Salpingo-oophorectomy. — If  the  flexion  is  caused  by,  or  at  least 
combined  with,  inflammation  of  the  uterine  appendages,  and  milder 
means  do  not  lead  to  a  satisfactory  result,  much  benefit  may  be  ob- 
tained by  removal  of  these  organs. 

C.  Retroversion. 

The  retrodeviations  or  displacements  backward  of  the  uterus  are 
twofold— retroversion,  corresponding  to  anteversion  ;  and  retroflexion, 
corresponding  to  anteflexion. 

In  retroversion  the  uterus  as  a  whole  is  tipped  backward  over  a 
transverse  axis.  According  to  the  degree  to  which  the  tilting  is  car- 
ried the  os  points  downward  or  forward  against  the  symphysis'  pubis, 
and  the  fundus,  just  opposite  it,  turns  upward  or  backward  toward  the 
sacrum.  The  longitudinal  axis  is  straight.  In  most  cases  retroversion 
1  E.  C.  Dudley  of  Chicago,  Amer.  Jour.  Obst.,  1891,  vol.  xxiv.,  p.  142. 


DISEASES  OF  THE   UTERUS. 


443 


is  only  a  transition  to  retroflexion  ;  the  pathology,  the  symptoms,  and 
the  treatment  are  identical,  and,  since  the  flexion  is  so  much  more  com- 
mon than  the  version,  we  prefer  to  describe  them  under  that  heading. 
Diagnosis. — We  have  seen  above  (p.  440)  that  the  direction  of  the 
cervix  might  lead  one  to  think  of  anteflexion,  but  by  bimanual  exam- 
ination and  the  sound  the  direction  of  the  fundus  backward  is  easily 
made  out.  An  anteflexed  uterus  may  at  the  same  time  be  retroverted. 
Then  it  is  curved  or  bent  forward,  os  and  fundus  being  approxi- 
mated in  front  of  the  anterior  surface,  and  this  curved  uterus  is  tilted 
backward  as  a  whole.  In  these  cases  the  os  is  turned  forward  and 
upward,  the  fundus  or  the  posterior  surface  is  felt  lying  against  the 
rectum,  the  anterior  surface  is  felt  concave,  and  the  posterior  convex. 
The  difference  between  retroversion  and  retroflexion  is  that  in  version 
the  uterus  forms  a  straight  line,  while  in  flexion  it  is  bent  with  the 
concavity  backward. 

D.  Retroflexion. 

Retroflexion  is  that  displacement  in  which  the  body  of  the  uterus 
is  bent  backward,  the  cervix  remaining  in  its  normal  position  (Fig. 

FJG.  249. 


Retroflexion  of  the  Uterus  (Fritsch). 

249).     It  is  often  combined  with  retroversion,  when  the  os  points 
downward  and  forward. 


444  DISEASES  OF  WOMEN, 

Pathological  Anatomy. — Besides  the  peculiar  shape  of  the  uterus, 
we  find,  as  a  rule,  signs  of  chronic  raetritis,  and  often  of  pelvic  peri- 
tonitis, salpingitis,  oophoritis,  or  cellulitis.  In  many  cases  adhesions 
are  found  between  the  posterior  surface  and  the  rectum  or  between  the 
appendages  and  broad  ligaments  and  the  posterior  wall  of  the  pelvis. 
Most  of  these  adhesions  are  thread-like  and  friable ;  others  are  spread 
over  a  large  surface  and  very  tough. 

The  uterus  is  commonly  enlarged,  situated  lower  down  than  normal, 
and  has  a  large  os  and  a  thick  cervix. 

Retroflexion  may  by  twisting  the  broad  ligaments  interfere  with  the 
free  circulation  in  the  pelvic  veins. 

Etiology. — Retroflexion  may  be  congenital,  but  that  is  much  rarer 
than  congenital  anteflexion.  As  a  rule,  it  is  acquired.  It  may  be 
due  to  subinvolutiou  after  childbirth.  Parts  of  the  placenta  may  re- 
main attached  to  the  anterior  wall  and  cause  incomplete  involution,  by 
which  the  anterior  wall  becomes  larger  than  the  posterior,  and  a  retro- 
flexion  is  the  result.  A  frequently  over-filled  bladder  may  predispose 
to  it.  In  the  normal  condition  the  abdominal  pressure  from  above 
in  the  erect  posture  keeps  the  uterus  in  an  anteverted  and  often 
slightly  anteflexed  position  ;  but  when  the  fundus  is  lifted  up,  so 
that  the  direction  of  the  pressure  comes  to  lie  in  front  of  it,  the  uterus 
is  more  and  more  tipped  and  bent  backward.  This  will  be  favored 
by  weakness  of  the  round  and  broad  ligaments,  which  again,  in  most 
cases,  is  a  sequel  of  childbirth. 

This  tilting  may  also  be  due  to  elongation  of  the  cervical  portion, 
or  to  shallowuess  of  the  cul-de-sac  at  the  posterior  vaginal  fornix. 
The  most  common  cause  is  some  form  of  perimetric  inflammation. 
Endometritis,  very  often  gonorrheal  in  origin,  leads  to  salpiugitis,  the 
inflammation  spreads  to  the  peritoneum,  and  adhesions  are  formed 
between  the  broad  ligaments,  the  appendages,  and  the  uterus  on  one 
side,  and  the  posterior  wall  and  the  floor  of  the  pelvis  with  the  rec- 
tum on  the  other,  which  adhesions  drag  these  organs  with  them 
backward  and  downward.  In  other  cases  the  inflammation  may 
spread  directly  through  the  wall  of  the  uterus,  and  cause  parenchy- 
matous  raetritis  and  perimetritis  with  adhesions  between  the  fundus 
and  posterior  surface  of  the  uterus  in  front  and  the  rectum  behind. 

Symptoms. — In  rare  cases  retroflexion  does  not  give  rise  to  any 
symptoms.  In  most  they  are  those  usually  found  in  uterine  disease, 
and  especially  in  chronic  metritis  (p.  416) :  pain,  dysmenorrhea,  men- 
orrhagia,  metrorrhagia,  leucorrhea,  dyspareunia,  and  dysuria.  Ster- 
ility is  not  so  common  as  in  anteflexion,  the  direction  of  the  uterine 
canal  being  more  favorable  for  the  entrance  of  the  semen.  Consti- 
pation is  very  common,  and  is  easily  explained  by  the  mechanical 
obstruction  offered  by  the  fundus  pressing  against  the  rectum.  Ner- 
vous reflexes  and  general  malnutrition  arej  as  a  rule,  prominent 
features. 


DISEASES   OF  THE    UTERUS.  445 

Diagnosis. — By  bimanual  examination  the  peculiar  shape  and  posi- 
tion of  the  uterus  are  easily  made  out.  It  is  not  enough  to  feel  a 
mass  in  the  posterior  cul-de-sac  of  the  vagina.  That  may  as  well  be 
a  fibroid  in  the  posterior  wall  of  the  uterus  or  an  exudation  or  a  .sar- 
coma in  Douglas's  pouch.  If  the  uterus  cannot  be  mapped  out,  the 
direction  of  the  uterine  cavity  may  be  ascertained  with  the  sound  or 
probe. 

There  are  cases  of  flabby  uterus  without  adhesions  in  which  the 
corpus  moves  at  the  level  of  the  internal  os,  as  if  there  were  a  hinge, 
and  the  uterus  is  sometimes  found  anteflexed  and  at  other  times  retro- 
flexed. 

A  chief  point  in  the  diagnosis  is  to  discover  whether  the  uterus  is 
movable  or  bound  by  adhesions.  For  this  purpose  examination  in 
the  dorsal  decubitus  is  insufficient.  Sometimes  a  uterus  can  be 
replaced  with  the  sound  in  this  position  in  such  a  way  that  the  ante- 
rior wall  of  the  rectum  follows  the  uterus.  This  is  not  the  case  in 
the  genu-pectoral  position.  By  introducing  a  finger  into  the  rectum 
in  this  position  the  adhesions  are  felt  as  tense  bands. 

Sometimes  it  is  possible,  under  ether,  to  replace  a  retroflexed  uterus 
which  seems  immovable,  and  to  retain  it  by  a  pessary. 

Prognosis. — In  the  great  majority  of  cases  we  may  expect  to  cure 
the  patient,  or  at  least  make  her  comfortable,  with  a  pessary.  Retro- 
displacements  predispose  to  prolapse.  If  pregnancy  occurs,  a  serious 
condition  may  be  brought  about  in  case  the  uterus  does  not  rise  spon- 
taneously out  of  the  pelvis.  In  some  cases  operations  are  necessary 
in  order  to  procure  relief,  and  in  the  laboring  classes,  in  which  harder 
work  is  combined  with  less  cleanliness  and  care,  they  are  preferable 
to  pessaries. 

Treatment. — If  the  uterus  and  its  surroundings  are  tender,  the 
inflammation  should  be  combated  with  hot  vaginal  douches  (p.  171), 
painting  with  iodine  (p.  170),  and  ichthyol  or  glycerin  tampons  (p. 
178)  before  any  attempt  is  made  to  replace  and  retain  the  uterus  in  a 
better  position.  If  there  are  signs  of  chronic  metritis,  curetting  (p. 
176)  and  packing  with  iodoform  gauze  (p.  180)  may  reduce  the  bulk 
of  the  uterus  and  form  a  useful  introduction  to  other  measures. 

Replacement. — The  retroflexed  uterus  may  be  replaced  in  different 
ways. 

Air-pressure. — One  way  is  to  place  the  patient  in  the  genu-pectoral 
position  (p.  138)  and  introduce  Sims's  speculum.  In  rare  cases  this 
may  suffice  to  make  the  fundus  uteri  spontaneously  sink  forward. 
The  pressure  may  be  increased  by  means  of  a  sponge  on  a  sponge- 
holder  or  a  cotton  tampon  held  in  a  dressing-forceps  applied  against 
the  posterior  vaginal  vault. 

Bimanual  Manipulation. — Another  way  is  to*  place  the  patient  in 
the  dorsal  decubitus,  introduce  one  or  two  fingers  into  the  vagina,  and 


446  DISEASES  OF  WOMEN. 

press  their  tips,  with  the  volar  surface  turned  up,  into  the  posterior 
vault.  The  four  fingers  of  the  other  hand  are  inserted  above  the 
syrnphysis  pubis  and  press  the  abdominal  wall  down  until  the  fundus 
of  the  uterus  is  reached  and  can  be  pulled  forward,  while  the  vaginal 
fingers  push  in  the  same  direction.  This  method  can  only  be  used 
on  rather  lean  patients. 

Digital  Pressure. — A  good  way  is  to  place  the  patient  in  Sims's  posi- 
tion and  introduce  the  middle  and  index-fingers  into  the  vagina  with 
the  dorsal  surface  turned  against  the  back  of  the  uterus,  and  press 
upward  and  forward.  If  the  uterus  is  enlarged,  some  advantage  is 
obtained  by  directing  the  pressure  toward  the  sacro-iliac  synchondrosis. 

Pepositors. — Special  instruments  have  been  invented  for  replacing 
the  uterus,  but  the  simplest  way  is  to  do  it  with  the  uterine  sound. 
It  is  introduced  as  described  on  p.  152,  but  with  the  concavity  turned 
backward,  and  when  the  knob  has  passed  the  internal  os  the  handle 
is  pushed  forward  until  the  knob  touches  the  fundus.  Then  the 
handle  is  made  to  circumscribe  one-half  of  a  large  circle,  so  as  to  keep 
the  knob  on  the  same  point  in  the  interior  of  the  uterus.  When  the 
concavity  turns  forward,  the  handle  is  brought  gently  back,  the  index- 
finger  of  the  left  hand  helping  to  tilt  the  uterus  forward  by  pressing 
on  its  posterior  surface.  As  soon  as  a  resistance  is  felt  or  the  reposi- 
tion causes  pain,  the  operation  should  be  discontinued. 

Pessaries. — When  the  uterus  is  replaced,  it  is  kept  in  the  normal 
position  by  means  of  a  pessary.  The  best  is  Emmet's  modification 
of  Hodge's  (Fig.  250).  It  is  made  of  hard  rubber,  and  is  introduced 

FIG.  250. 


Hodge-Emmet  Pessary. 

in  the  following  way :  The  patient  being  in  Sims's  position,  and 
the  doctor  standing  behind  her  back,  the  pessary  is  seized  by  the 
lower,  narrow  end  with  the  right  thumb  and  index-finger,  lubri- 
cated, and  held  in  the  sagittal  plane  in  front  of  the  vulva.  With 
the  left  thumb  and  index-finger  the  labia  are  separated,  and  the 
pessary  is  pushed  through  the  vaginal  entrance  pressing  upward 
toward  the  promontory  and  backward  against  the  perineum. 
When  the  broadest  part  has  passed  the  vaginal  entrance,  the  pessary 


DISEASES  OF  THE   UTERUS.  447 

is  turned  into  the  coronal  plane.  Next  the  lower  end  is  seized  with 
the  left  thumb  and  index-finger,  and  the  right  index-finger  is  applied 
to  the  inside  of  the  upper  arch,  which  by  a  combined  movement  with 
both  hands  is  brought  up  behind  the  cervix,  as  high  up  as  possible. 
Finally,  the  right  index-finger  is  inserted  in  front  of  the  lower  arch 
and  pushes  it  back,  the  effect  of  which  is  to  push  the  upper  arch  well 
forward  against  the  posterior  surface  of  the  uterus.  Beginners  are 
apt  to  insert  the  pessary  in  front  of  the  cervix,  but  by  following  the 
above  directions  they  will  soon  succeed  in  placing  it  behind  the  same. 

In  a  spacious  vagina  the  pessary  may  be  introduced  while  pull- 
ing the  perineum  back  with  Sims's  speculum,  a  method  which  offers 
the  advantage  that  the  hand  is  guided  by  the  eye. 

Most  pessaries  on  the  market  have  too  strong  a  curvature.  This 
may  be  remedied  by  dipping  them  in  oil  and  heating  them  in  the 
flame  of  an  alcohol  lamp,  when  the  hard  rubber  becomes  soft  and 
can  be  shaped  at  will.  A  well-fitting  pessary  extends  from  the  depth 
of  the  posterior  cul-de-sac  to  the  vaginal  entrance,  and  takes  its  sup- 
port there.  It  follows  the  normal  curvature  of  the  vagina.  The 
lower  end  is  bent  back  a  little,  so  as  to  avoid  pressure  on  the  urethra. 

If  there  is  much  tenderness  of  the  womb  or  a  displaced  ovary,  the 
pressure  of  the  hard-rubber  pessary  sometimes  becomes  intolerable. 
In  such  cases  one  of  a  similar  shape,  but  made  of  whalebone  covered 
with  soft  rubber,  may  yet  prove  useful.  Practitioners  will  find  a 
great  variety  of  pessaries  in  the  stores  and  catalogues  which  we  can- 
not enumerate  in  a  work  of  this  kind. 

If  the  posterior  cul-de-sac  is  too  shallow  to  allow  the  Hodge  pes- 
sary to  penetrate  far  enough  along  the  posterior  uterine  surface  to  keep 
the  corpus  bent  forward,  it  is  apt  to  bend 
backward  over  the   pessary,  which    then  Fl«-  251. 

does  more  harm  than  good.  To  obviate 
this  the  vagina  may  be  deepened  by  meth- 
odical packing  (p.  178).  In  exceptional 
cases  I  have  succeeded  with  Fowler's 
pessary  (Fig.  251)  when  others  failed. 

Some  use  the  intra-uterine  stem  with  or  

without  Vaginal  Support  (p.  441).  Fowler's  Pessary. 

Postural  Treatment. — Some  help  may 
be  derived  in  the  treatment  of  retroflexion  by  directing  the  patient  to 
spend  the  night  on  her  abdomen,  or  at  least  on  the  sides  in  a  semi- 
prone  position,  and  to  avoid  lying  on  her  back.  Besides,  it  is  recom- 
mended to  let  her,  on  retiring,  take  the  knee-chest  position,  and  pull 
back  the  perineum  with  a  finger,  or,  better,  introduce  a  glass  tube  that 
will  admit  the  air  right  up  to  the  vault.1 

In  many  women  it  is  only  necessary  to  use  the  Hodge  pessary  for 
1  Henry  F.  Campbell,  Gyn.  Trans.,  1885,  vol.  x.,  p.  305. 


448  DISEASES  OF  WOMEN. 

some  time,  say  from  three  to  six  months.  Others  need  it  all  their 
lives. 

General  remarks  about  pessaries  are  found  on  p.  436.  An 
elastic  abdominal  belt  (p.  190)  may  be  useful,  especially  in  stout 
patients. 

If  these  milder  means  do  not  succeed  in  curing  or  relieving  the 
patient,  recourse  may  be  had  to  different  operations — viz.  perineor- 
rhaphy,  trachelorrhaphy,  excision  of  cervix,  extraperitoneal  shorten- 
ing of  the  round  ligaments,  forcible  tearing  of  adhesions,  massage, 
hysteropexy,  and  intraperitoneal  shortening  of  ligaments. 

1.  Perineorrhaphy. — If  the  vaginal  entrance  is  torn,  and  the  pessary 
does  not  find  the  necessary  support,  the  perineum  must  be  repaired 
(p.  307). 

2.  Trachelorrhaphy  and  Wedge-shaped  Excision  of  Cervix. — If  the 
cervix  is  torn,  it  should  be  brought  together  (p.  399),  and  even  if  it 
is  not  torn,  but  bulky  and  presenting  a  large  canal,  Gordon's  operation 
(p.  418)  should  be  performed.     The  involution  caused  in  the  body 
of  the  uterus  by  operations  on  the  cervix  (p.  418)  is  in  many  cases, 
together  with  postural  and  astringent  treatment,  sufficient  to  ensure 
the  reposition  of  the  displaced  womb.1 

3.  Extraperitoneal    Shortening  of   the   Round    Ligaments   (Alex- 
ander's Operation). — This  operation  is  chiefly  indicated  in  cases  where 
there  are  no  adhesions.     Its  object  is  to  keep  the  fund  us  forward  by 
removing  a  part  of  the  round  ligaments  without  opening  the  abdom- 
inal cavity.      It  is  contraindicated  in  women  who  have  passed  the 
menopause,  as  this  event  entails  fatty  degeneration  and  atrophy  of 
the  ligaments. 

Modus  Operandi. — The  patient  lies  stretched  out  at  full  length  on 
her  back.  The  operator  stands  on  the  side  of  the  table  opposite  to 
the  ligament  to  be  operated  on.  The  pubic  hairs  are  shaved  off. 
The  operator  feels  for  the  spine  of  the  pubis,  and  makes  with  his  nail 
a  little  dent  in  the  skin  over  it.  An  incision  is  made  parallel  to 
Poupart's  ligament  from  1^  to  3  inches  in  length,  according  to  the 
amount  of  subcutaneous  adipose  tissue,  passing  through  the  dent 
and  going  down  to  the  tendon  of  the  obliquus  externus  abdom- 
inis  muscle.  The  left  index-finger  is  placed  on  the  pubic  spine  and 
the  pillars  of  the  ring,  and  the  intercolumnar  fascia,  with  its  trans- 
verse fibers,  laid  bare  by  scraping  with  the  handle  of  the  scalpel. 
The  ring  is  situated  immediately  above  and  a  little  outside  of  the 
spine.  Bleeding  vessels  are  tied  or  compressed.  From  the  ring 
emerges  a  bunch  of  adipose  tissue  that  contains  the  ends  of  the  round 
ligament,  which  spread  out  in  fine  filaments  often  hard  to  distinguish. 
This  whole  mass  is  seized  with  a  pressure-forceps,  and  an  aneurism- 

1  Gordon  and  Engelmann,  International  Medical  Congress,  1884,  C&mpte-rendu  des 
travaux  de  la  Section  <f  Obstetrique  et  de  Gynecologie,  pp.  157-160. 


DISEASES  OF  THE    UTERUS.  449 

needle  inserted  under  it  close  to  the  bone.  Next  we  pull  on  the  mass, 
and  see  the  white  genital  branch  of  the  genito-crural  nerve,  which  lies 
just  in  front  or  to  one  side  of  the  ligament.  It  is  severed  with  knife 
or  scissors,  and  so  are  some  fine  tendinous  fibers  running  from  the  lig- 
ament to  the  wall  of  the  canal.  Sometimes  the  peritoneum  is  invagi- 
nated  and  accompanies  the  ligament,  from  which  it  must  be  stripped 
with  the  fingers  and  pushed  back.  When  the  ligament  begins  to  peel 
out  easily,  this  side  is  covered  with  an  antiseptic  pad. 

The  operator  now  steps  over  to  the  other  side  of  the  table,  and 
repeats  the  operation  on  the  other  ligament. 

When  both  ligaments  are  free,  an  assistant  pushes  the  uterus  for- 
ward with  the  sound  or  a  repositor,  and  the  ligaments  are  pulled  out 
from  2  to  4  inches  until  we  meet  with  a  decided  resistance. 

Next,  the  ligaments  are  secured  in  their  new  position  by  passing 
two  or  three  sutures  of  silk  or  chromicized  catgut  through  the  pillars 
and  the  ligament,  whereby  we  should  keep  outside  of  the  center  of 
the  ligament  in  order  not  to  tie  the  artery  running  there  (p.  60),  which 
might  lead  to  sloughing.  It  is  well  to  carry  the  last  suture,  not  only 
through  the  pillars,  but  through  the  fibrous  tissue  covering  the  pubes. 

Finally,  the  redundant  part  of  the  ligament  is  cut  off,  the  edges  of 
the  superficial  fascia  united  with  a  running  catgut  suture,  and  the  ex- 
ternal wound  closed  with  interrupted  silk  or  silkworm-gut  sutures. 
In  very  fat  women,  or  if  the  tissues  have  been  much  bruised,  a  soft- 
rubber  drainage-tube  is  left  in  the  whole  length  of  the  wound.  An 
antiseptic  dressing  is  put  on  and  left  for  a  week.  Then  the  outer 
sutures  are  removed.  The  patient  is  kept  in  bed  for  a  month,  and 
should  wear  a  Hodge's  pessary  for  six  months  or  longer.  If  Alex- 
ander's operation  is  combined  with  perineorrhaphy,  the  pessary  is 
introduced  at  the  end  of  four  weeks. 

If  the  ligament  cannot  be  found  or  breaks,  it  is  necessary  to  split 
the  anterior  wall  of  the  inguinal  canal. 

Nobody  should  undertake  this  operation  without  having  tried  it 
several  times  on  the  cadaver,1  since  even  experienced  surgeons  have 
found  it  difficult  or  impossible  to  find  the  ligaments. 

If  there  are  signs  of  endometritis,  it  is  a  good  plan  to  curette  the 
uterus  before  performing  Alexander's  operation. 

Several  cases  of  childbirth  after  this  operation  are  on  record. 

If  the  fundus  is  held  back  by  adhesions,  a  transverse  incision  should 
be  made  in  the  vagina,  behind  the  cervix,  as  in  hysterectomy,  and  the 
adhesions  should  be  torn  with  the  fingers  or  cut  with  the  thcrmo-cau- 
tery.  If  there  is  no  bleeding  the  opening  may  be  closed  immediately. 

1  It  is  also  advisable  to  study  the  papers,  full  of  practical  details,  published  bv 
Polk  in  N.  Y.  Med.  Record,  July,  1886,  p.  1 ;  Munde,  in  Amer.  Jonr.  Obntef.,  Nov", 
1888,  vol.  xxi.  p.  1121 ;  and  J.  H.  Kellogg,  Trans.  Amer.  Assoc.  of  Obstetricians  and 
Gynecologists,  1888,  vol.  i.  p.  223. 
29 


450  DISEASES  OF  WOMEN. 

Otherwise  it  is  packed  with  iodoform  gauze.     When  the  adhesions 
are  disposed  of,  Alexander's  operation  is  performed  in  the  usual  way. 

4.  Forcible  Tearing  of  Adhesions  (Schnitzels  Method}. — When  the 
uterus  is  bound  down  with  adhesions  Schultze  dilates  the  cervical 
canal  with  aseptic  latuinaria  (p.  154).     He  introduces  the  index-  and 
middle  fingers  into  the  vagina,  and  the  latter  up  to  the  fundus.    Next 
he  uses  this  finger  to  replace  the  uterus,  while  the  other  hand  grasps 
it  through  the  abdominal  wall.     Wrhen  the  uterus  is  replaced,  it  is 
kept  in  situ  with  a  pessary.     Most  adhesions  are  easily  separated,  and 
the  operator  will,  of  course,  use  a  good  deal  of  judgment  in  deciding 
which  resistance  he  will  try  to  overcome,  and  when  to  desist,  but  on 
account  of  the  uncertainty  as  to  the  conditions  found  in  the  pelvis, 
this  method  is  fraught  with  dangers,  which  are  still  enhanced  by 
substituting  a  thick  sound  for  the  finger.1     It  is  much  safer  to  open 
the  cul-de-sac. 

5.  Massage  (Brandtfs  Method). — Not  less  efficacious  and  safer  than 
Schultze's  is  Brandt's  method,  that  obtains  similar  results  by  means 
of  manipulations  directed  through  the  abdominal  wall  and  the  vagina 
(p.  190).     By  this  method  the  adhesions  are  stretched  gradually,  and 
made  to  be  absorbed  by  increase  in  vital  processes.2     If,  however, 
there  be  a  pyosalpinx  or  other  purulent  collection  in  the  pelvis,  the 
pus  may  be  pressed  into  the  peritoneal  cavity  and  cause  an  acute 
inflammation  that  may  end  fatally. 

6.  Hysteropexy,  or  Womb-fastening.3 — There  are  different  operations 
by  which  the  uterus  is  stitched  to  other  parts  in  order  to  make  it 
adhere  in  a  position  that  prevents  it  from  falling  back  again.     They 
may  be  divided  into  two  classes,  according  to  the  point  chosen  for 
the  adhesion — viz.  vaginal  hysteropexy  and  abdominal  hysteropexy. 

A.  Vaginal  Hysteropexy  or  Vagino-Jixation. — The  patient  is  in 
the  dorsal  position  with  raised  feet.  Garrigues'  self-retaining  weight 
speculum  (Fig.  177,  p.  211)  and  Engelmann's  side  retractors  are  intro- 
duced. The  uterus  is  pulled  downward  and  backward  as  far  as  pos- 
sible with  two  volsellse  or  bullet-forceps,  one  on  either  lip  of  the  cer- 
vical portion.  Another  bill  let- forceps  is  fastened  in  the  median  line 
of  the  vagina,  about  an  inch  behind  the  meatus  urinarius.  The  ante- 
rior wall  having  been  put  on  the  stretch,  an  incision  is  made  through 
the  mucous  membrane,  extending  from  the  upper  forceps  down  to  the 
line  of  demarkation  between  the  bladder  and  the  cervix,  which  is  as- 
certained by  introducing  a  metal  catheter  into  the  bladder  or  by  the 
difference  of  the  rugosities  of  the  vagina  and  the  smooth  surface  of 
the  vaginal  portion  of  the  uterus.  Next,  the  mucous  membrane  is 

1  Erich  of  Baltimore,  Amer.  Jour.  Obst.,  Oct.,  1880,  vol.  xiii.  p.  836';  Van  de 
Warker  of  Syracuse,  Gyn.  Trans.,  1881,  vol.  vi.  p.  185. 

2  For  details  the  reader  is  referred  to  Dr.  Vineberg's  paper,  quoted  on  p.  188. 

3  Hystera,  womb ;  pegnymi,  I  fasten.     This  name  is  more  correct  than  hysterori-haphy, 
which  only  means  womb-sewing. 


DISEASES  OF  THE  UTERUS.  451 

partly  dissected,  partly  pushed  back  with  blunt  instruments  from  the 
bladder  to  the  extent  of  an  inch  to  either  side  of  the  incision.  There- 
after the  bladder  is  in  a  similar  way  separated  from  the  uterus,  com- 
mencing with  a  transverse  incision  of  the  cervix.  A  strong  silk  thread 
is  passed  with  a  strong  curved  needle  transversely  through  the  an- 
terior wall  of  the  uterus,  and  serves  to  pull  the  uterus  down,  so  that 
another  thread  can  be  inserted  half  an  inch  higher  up,  which  is  used 
in  a  similar  way  until  a  third  can  be  inserted,  and  finally  the  fundus 
of  the  uterus  appears  in  the  wound.  Instead  of  these  traction  threads 
bullet-forceps  may  be  used  for  anteverting  the  uterus,  if  the  tissue  is 
hard  enough  not  to  tear  out. 

When  the  fundus  has  been  reached,  a  silk  suture  is  passed  through 
it  from  side  to  side,  but  not  tied.  Two  more  are  inserted  parallel  to 
the  first  and  below  it,  with  about  half  an  inch  interval.  Each  of  the 
six  ends  is  carried  by  means  of  a  silk  loop  (p.  401)  through  the  loos- 
ened mucous  membrane,  far  out  to  the  side.  Then  all  the  traction 
threads  are  removed,  the  edges  of  the  vaginal  incision  are  united  by 
a  continuous  catgut  suture,  which  in  the  lower  part  enters  the  tissue 
of  the  cervix,  and  finally  the  three  deep  sutures  are  tied  across  the 
vagina. 

The  patient  is  kept  in  bed  for  two  weeks,  and  the  sutures  are 
removed  at  the  end  of  four  weeks  after  the  operation.1 

After  the  menopause,  when  Alexander's  operation  is  contraindi- 
cated,  vaginal  hysteropexy  may  answer  a  good  purpose.  During  the 
ohildbearing  period  it  exposes  to  pain  during  pregnancy,  abortion,  or 
great  difficulties  in  delivery,  even  the  Cesarean  section  having  become 
necessary  on  account  of  the  unnatural  position  of  the  os  upward  and 
backward,  which  prevented  engagement  of  the  fetus.  In  virgins 
Alexander's  operation  is  also  preferable,  in  order  to  avoid  undue 
distention  of  the  vagina. 

The  appendages  can  easily  be  drawn  down  into  the  wound,  in- 
spected, and,  if  diseased,  they  may  be  removed. 

If  the  retroflexion  is  complicated  with  a  cystocele,  a  part  of  the 
mucous  membrane  of  the  vagina  may  be  cut  off  before  uniting  the 
«dges  of  the  wound. 

If  there  is  any  difficulty  in  raising  the  uterus,  it  may  be  done  with 
a  thick  uterine  sound  having  a  uterine  and  a  perineal  curvature. 

If  the  uterus  is  adherent  in  the  hollow  of  the  sacrum,  a  transverse 
incision  should  be  made  at  the  utero-vaginal  junction,  behind  the  cer- 
vix, large  enough  to  admit  two  fingers,  with  which  the  adhesions  are 
severed.  If  there  is  any  bleeding,  the  pelvic  cavity  is  tamponed  witli 
iodpform-gauze  or  sterilized  gauze.  (See  Hysterectomy.) 

1  Mackenrodt,  Deutsche  med.  Wochenschr.,  1892,  No.  22,  with  improvements  by 
Winters  (Centralbl.  f.  Gyndk.,  1893,  No.  27,  p.  627),  Duhrssen  (ibid.,  No.  30,  p.  690), 
Orthmann  (ibid.,  No.  45,  p.  1038),  and  others. 


452  DISEASES  OF  WOMEN. 

B.  Abdominal  Hysteropexy,  or  Ventro-fixation  of  the  Uterus. — In 
this  operation  the  uterus  is  attached  to  the  abdominal  wall.  There 
are  many  varieties,  the  most  important  being  the  following — viz. : 

a.  Olshausen's  Method. — One  suture  is  carried  through  the  round 
ligament  near  the  edge  of  the  uterus  and  the  anterior  layer  of  the 
broad  ligament  behind,  and  the  parietal  peritoneum  and  part  of  the 
the   rectus   abdominis   muscle   in  front,  three-quarters   of  an    inch 
from  the  middle  line.     Two  more  sutures  are  inserted   below  the 
first,  only  through  the  anterior   layer  of  the  broad  ligament  and 
the  abdominal  wall  as  just  stated.    All  six  sutures  are  inserted  before 
any  of  them  is  tied.     The  uterus  should  be  lifted  sufficiently  to  leave 
only  a  narrow  slit  between  it  and  the  bladder.     Before  tying,  the 
operator  makes  sure  that  neither  the  intestine  nor  the  omentum  is 
in  the  way. 

b.  Leopold's  Method. — Leopold    fastens   the   uterus   itself  to   the 
abdominal  wall.     A  suture  is  carried  through  the  whole  abdominal 
wall  and  transversely  under  the  peritoneum  and  the  most  superficial 
part  of  the  muscular  tissue  on  the  anterior  surface  of  the  uterus, 
between  the  two  starting-points  of  the  round  ligaments,  on  a  line 
half  an  inch  long,  and  then  out  through  the  abdominal  wall  on  the 
other  side.     Two  more  such  sutures  are  placed  above  the  first  and 
parallel  to  it. 

In  order  to  insure  adhesion  the  perimetrium  is  scraped  with  the 
back  of  a  bistoury  in  the  space  comprised  between  these  sutures. 

Other  sutures  are  carried  through  the  abdominal  wall  alone,  below 
and  above  those  going  through  the  uterus,  and  finally  all  are  tied. 
Those  going  through  the  uterus  are  left  in  place  from  twelve  to 
fifteen  days. 

c.  Czemy's  Method  is  like  Leopold's,  with  this  difference  that  he  uses 
only  two  uterine  sutures  of  catgut  treated  with  corrosive  sublimate, 
and  carries  them  only  through  the  peritoneum,  muscle,  and  fascia,  but 
not  through  the  integument. 

d.  Pozzi's  Method. — Beginning  at  the  lower  end  of  the  incision,  a 
continuous  suture  of  fine  silk  is  brought  through  the  abdominal  wall, 
except  the  skin  and  sucutaneous  adipose  tissue  (as  in  Czerny's  method), 
and  through  the  perimetrium,  which  is  comprised  three  times  in  the 
suture.     The  remainder  of  the  abdominal  wall  is  closed  with  a  con- 
tinuous tier-suture  of  catgut,  in  two  layers  (p.  221). 

e.  Kelly's  Method} — A  ligature  is  carried  through  the  parietal  peri- 
toneum and  adjacent  tissue  one-eighth  of  an  inch  deep  and  a  third  of 
an  inch  wide  and  through  the  posterior  wall  of  the  uterus,  below  the 
fund  us  and  finally  through  the  peritoneum  and  adjacent  tissue  on  the 
other  side.     When  this  suture  has  been  tied,  a  second  is  carried  in  a 

1  Howard  Kelly,  "  Suspension  of  the  Uterus,"  Jour.  Amer.  Ned.  Assoc.,  Dec.  21, 
1895,  vol.  xxv.  p.  1079. 


DISEASES  OF  THE   UTERUS.  453 

similar  way  just  above  the  first  on  the  abdominal  wall  and  below  it 
on  the  posterior  wall  of  the  uterus.  Adhesions  form  at  once,  but 
stretch,  so  that  after  a  short  time  the  organ  is  found  mobile,  with  the 
fundus  well  forward  in  an  easy  anteflexion  and  with  a  marked  space 
between  it  and  the  abdominal  wall  to  which  it  was  attached. 

/Severance  of  Adhesions. — In  all  cases  in  which  the  abdominal  cav- 
ity is  opened,  adhesions  that  hold  the  uterus  in  its  faulty  position 
should  be  severed,  beginning  at  the  distal  end  of  the  broad  ligaments. 
As  a  rule,  this  can  be  done  with  the  finger  alone,  but  sometimes  the 
adhesions  are  so  tough  that  they  have  to  be  tied  with  a  double  liga- 
ture and  cut  with  scissors,  or  they  have  to  be  severed  with  the  thermo- 
or  electro-cautery.  If  there  is  much  bleeding  from  torn  adhesions, 
it  may  become  necessary  to  use  a  provisional  intra-abdominal  tampon 
of  iodoform  gauze  (p.  181). 

Examination  of  Appendages.— When  the  abdomen  is  opened,  the 
appendages  should  be  brought  into  view,  and,  if  seriously  affected, 
they  should  be  removed.  .In  the  latter  case  either  the  stumps  or  the 
fundus  uteri  may  be  fastened  to  the  abdominal  wall. 

Pessary. — In  all  cases  of  abdominal  hysteropexy  a  Hodge's  pessary 
should  be  introduced  and  worn  for  several  months. 

The  bladder  soon  accommodates  itself  to  its  new  relations  with  the 
uterus.  Pregnancy  and  childbirth  at  term  have  been  observed  after 
hysteropexy,  but  in  some  cases  abortion  has  occurred.  Strangulation 
of  the  intestine  or  the  omentum  in  the  slits  might  take  place,  but  this 
danger  does  not  seem  to  be  great.  It  is,  however,  serious  enough 
to  be  a  point  in  favor  of  other  operations  by  which  the  uterus  is  not 
fastened  to  the  abdominal  wall. 

7.  Intraperitoneal  Shortening  of  Ligaments — a.  Wylie's  Method.1 — 
The  round  ligaments  are  pulled  up  into  the  abdominal  wound,  scraped 
on  their  inner  surface  so  as  to  make  them  raw,  folded  upon  themselves, 
and  the  loop  tied  with  three  silk  sutures,  so  as  to  hold  the  uterus  over 
the  bladder  near  the  pubic  bone.  Then  the  abdominal  wound  is  closed. 

b.  Polk's  Method.2 — The  round  ligaments  are   caught   up  about 
three-quarters  of  an  inch  from  the  cornua,  are  approximated  in  front 
of  the  uterus,  and  are  tied  together  by  one  suture.     Should  further 
shortening  be  needed,  one  or  two  more  sutures  may  be  passed  in  front 
of  the  first  at  a  distance  of  a  quarter  or  half  an  inch  each. 

c.  Tait?s  Method  produces  a  shortening  of  the  round  ligaments  by 
passing  the  ligature  for  removal  of  the  appendages  (see  Diseases  of 
the  Tubes)  under  the  ligament,  so  as  to  comprise  a  loop  of  it  in  the 
part  that  is  cut  away. 

d.  Eode's  Method. — The  intra-peritoneal  shortening  is  performed 
from  the  vagina.     A  transverse  incision  is  made  in  front  of  the  cer- 

1  Gill  Wylie,  Amer.  Jour.  Obst.,  May,  1889,  vol.  xxii.  p.  484. 

2  W.  M.  Polk,  Oyn.  Trans.,  1889,  vol.  xiv.  p.  262. 


454  DISEASES  OF  WOMEN. 

vix.  (See  below,  Anterior  Colpotomy,  under  Uterine  Fibroids  and 
Salpingitis.)  The  uterus  is  turned  into  the  vagina  by  inserting 
bullet-forceps  one  above  the  other,  in  the  anterior  wall  of  the  uterus. 
After  examining  and  treating  the  appendages,  a  silk  ligature  is  car- 
ried with  a  needle  through  or  behind  the  round  ligament,  half  an  inch 
from  its  uterine  end,  from  right  to  left,  then  tied.  Next,  the  thread 
is  carried  about  two  inches  from  the  uterus,  from  left  to  right,  through 
the  same  round  ligament.  The  ends  of  the  thread  are  secured  with 
pressure-forceps  till  the  other  round  ligament  has  been  treated  in  the 
same  way.  Then  the  uterus  is  replaced  and  the  threads  tied  and  cut 
short.  The  wound  in  the  peritoneum  is  closed  with  catgut  sutures. 
The  vaginal  wound  may  be  closed  transversely  or  longitudinally.  In 
so  doing  the  bladder  is  again  united  to  the  cervix. 

Others  have  attacked  the  sacro-uterine  ligaments  and  the  infundi- 
bulo-pelvic  ligament. 

In  regard  to  the  laparotomy  forming  part  of  most  of  the  above- 
mentioned  methods  the  reader  is  referred  to  the  description  of 
Ovariotomy. 

In  the  writer's  opinion  it  is  hardly  warrantable  to  perform  laparot- 
omy for  retroflexiou  alone,  but  if  the  appendages  have  to  be  removed 
or  if  adhesions  cause  great  pain  and  cannot  be  disposed  of  otherwise, 
it  may  be  useful  to  attend  to  the  retroflexion  at  the  same  time  in  one 
of  the  ways  mentioned. 

E.  Lateroversion  and  Latei*oflexion. 

Lateral  deviations  of  the  uterus,  unaccompanied  by  other  patho- 
logical conditions,  are  rare.  They  may  be  congenital  (p.  394)  or  due 
to  inflammation  later  in  life.  The  displacement  is  often  produced  by 
inflammatory  exudations  in  the  pelvis  or  tumors  in  the  broad  liga- 
ments. The  diagnosis  is  made  by  bi manual  palpation  or  the  sound. 
These  displacements  are  apt  to  cause  sterility.  No  direct  treatment 
is  applicable. 

F.  Prolapse. 

Prolapse,  Prolapsus,  Descent,  Procidentia,  popularly  called  Falling 
of  the  Womb,  is  that  displacement  of  the  uterus  in  which  it  sinks 
down  to  a  lower  position  than  normal.  Some  authors  reserve  the 
term  "  prolapse  "  for  the  lesser  degrees  of  descent,  in  which  the  uterus 
is  inside  of  the  vagina,  and  designate  by  "  procidentia "  only  the 
highest  degree,  in  which  the  uterus  sinks  more  or  less  completely  out 
of  the  body  and  hangs  between  the  thighs.  Others  call  the  first 
degree  incomplete,  and  the  second  complete  prolapse. 

Prolapse  is  sometimes  acute  ;  that  is  to  say,  it  may  occur  suddenly 
in  an  otherwise  healthy  person,  even  a  virgin,  while  making  a  mus- 
cular effort,  but  this  is  rare.  It  has  also  been  observed  in  a  child, 


DISEASES  OF  THE   UTERUS.  455 

in  consequence  of  diarrhea,  a  few  days  after  birth.  Commonly  it  is 
chronic;  that  is  to  say,  it  is  developed  slowly  and  gradually.  In 
the  latter  case  it  is  combined  with  more  or  less  hypertrophy  and 
metritis. 

Pathological  Anatomy. — The  vagina  becomes  inverted,  as  in  supra- 
vaginal  hypertrophy  (p.  426),  but  in  prolapse  the  peritoneal  pouches 
in  front  and  behind  the  uterus  are  dragged  down  with  it  (Fig.  252). 

FIG.  252. 


Procidentia  Uteri,  with  pared  surfaces  for  Lefort's  operation:  A,  anterior  denudation;  B, 
posterior  denudation  ;  U,  fundus  uteri ;  UH,  meatus  urinarius;  .R,  rectum. 

HJtiology. — As  just  stated,  the  acute  prolapse  is  due  to  a  muscular 
effort  in  carrying  a  heavy  weight,  such  as  a  tub  with  water,  in  front 
of  the  body.  The  chronic  is  mostly  referable  to  childbirth.  The 
vaginal  entrance  being  ruptured  (pp.  302  and  305),  the  uterus  does 
not  find  its  usual  support  from  below.  It  becomes  retroverted 
and  then  retroflexed  (p.  443).  Intra-abdominal  pressure  drives 
it  like  a  wedge  down  through  the  vagina.  The  sacro-uterine  liga- 
ments (p.  55)  become  weakened  and  elongated,  the  pelvic  connective 
tissue  loses  its  touus,  and  the  weight  of  the  subinvoluted  vagina  drags 
the  uterus  down  (p.  336).  Finally,  the  uterus  sinks  by  its  own 
weight.  Thus  lack  of  support  from  above  and  below  combines  with 
weight,  pressure,  and  dragging  to  displace  the  uterus. 

The  descent  may  also  be  due  to  tumors  in  the  uterus,  which  increase 
its  weight,  or  in  the  abdomen,  which  press  on  it.  The  increase  in 
weight  and  succulence  of  all  pelvic  structures  caused  by  pregnancy 
may  also  result  in  prolapse. 


456 


DISEASES  OF  WOMEN. 


Symptoms. — The  symptoms  of  chronic  prolapse  are  identical  with 
those  of  hypertrophy  of  the  cervix  (p.  427).  The  acute  form  is 
accompanied  by  sudden  severe  pain,  faintness,  and  peritonitis. 

Diagnosis. — A  polypus  and  an  inverted  uterus  form  tumors  with- 
out the  opening  at  the  lower  end  leading  into  the  interior  of  the  tumor. 
Prolapse  differs  from  supravaginal  hypertrophy  by  the  low  position 
of  the  uterine  body  and  the  normal  or  only  slightly  increased  depth 
of  the  cavity.  The  lesser  degrees  of  prolapse  become  more  apparent 
in  the  erect  posture  (p.  138). 

Treatment. — As  a  rule,  common  pessaries  cannot  be  retained,  on 
account  of  lack  of  support  from  the  perineum.  A  large  soft-rubber 
ring,  an  inch  thick  (Mayer's  pessary),  will  sometimes  retain  the  uterus 
in  the  pelvis  by  distending  the  upper  part  of  the  vagina.  Breisky 
recommends  large  ovoid  bodies  of  hard  rubber.  Gariel's  air-pessaiy 
consists  of  a  soft-rubber  bag,  which  the  patient  can  introduce  herself 
into  the  vagina  and  fill  with  air.  In  most  cases  of  complete  prolapse 
it  is  necessary  to  use  supporters  composed  of  a  cup  and  stem  pressing 
against  the  vaginal  portion  and  fastened  to  an  abdominal  belt  (Fig. 

FIG.  253. 


Uterine  and  Abdominal  Supporter. 

253).     This  apparatus  is  removed  during  the  night,  and  the  cup 
cleansed  with  some  disinfectant. 

Brandts  method  of  combined  massage  and  gymnastic  movements 
(p.  191)  claims  great  triumphs  in  the  cure  of  prolapsus.1 

may  be  found  in  Boldt's 


DISEASES   OF  THE    UTERUS. 


457 


Operations. — As  a  rule,  combined  operations  are  required,  and  even 
they  may  not  always  prevent  a  return  of  the  evil.1 

Emmet's  or  other  operations  are  used  for  reducing  the  bulk  of  the 
uterus  (p.  418) ;  Alexander's  operation  (p.  448)  is  combined  with  peri- 
neorrhaphy  (p.  307) ;  vaginal  or  abdominal  hysteropexy  (pp.  451-453) 


Leforl's  Prolapsus  Operation :  A,  anterior  denudation  ;  B,  posterior  denudation ;  C  €',  upper 
right  lateral  sutures ;  D  jy,  upper  left  lateral  suture. 

is  also  used  to  hold  the  uterus  up,  in  order  to  fasten  the  uterus  above 
and  support  it  from  below. 

Le/orfs  Operation. — For  complete  prolapsus  Lefort's  operation  of 
partitioning  the  vagina  is  valuable  by  providing  a  solid  column  of  tis- 
sue right  in  the  middle  of  the  vagina  for  the  uterus  to  rest  on. 

In  the  middle  of  the  anterior  surface  of  the  tumor  hanging  in 
front  of  the  vulva  a  parallelogram  three-quarters  of  an  inch  wide  and 
over  two  inches  long  is  denuded  close  up  to  the  vulva.  Next,  the 
tumor  is  held  up  and  a  corresponding  denudation  is  made  on  the  pos- 
terior surface.  Then  the  uterus  is  replaced  sufficiently  to  bring  the 
two  upper  ends  of  the  pared  surfaces  in  contact,  and  to  unite  them 
with  three  or  four  sutures.  After  having  tied  these  sutures,  one  is 
inserted  on  either  side  of  the  parallelogram  (Fig.  254),  and  these  two 

1  I  combined  in  one  case  removal  of  the  appendages,  ventrofixation  of  the  uterus, 
Tail's  perineal  flap  operation,  and  Stolz's  cystocele  operation.  For  a  time  the  suc- 
cess was  complete,  but  a  year  had  not  elapsed  before  the  uterus  was  prolapsed  again. 


458  DISEASES  OF  WOMEN. 

also  tied,  by  which  the  uterus  is  lifted  still  more.  Thus  one  stitch  is 
placed  below  the  other,  half  a  dozen  on  either  side,  and  finally  the 
transverse  lines  forming  the  lower  ends  of  the  parallelograms  are 
brought  together  with  sutures. 

Lefort  uses  silver  wire  sutures  throughout,  leaving  them  long 
enough  to  hang  out  through  the  vulva,  but  the  upper  ones  are  diffi- 
cult to  remove.  It  is  probably  a  good  plan  to  combine  a  perineor- 
rhaphy  with  this  operation.1 

An  improvement  by  Coe2  consists  in  introducing  several  rows  of 
buried  catgut  sutures  in  the  middle  of  the  wound,  each  row  covering 
the  preceding  one.  Chromicized  catgut  is  particularly  well  adapted 
for  this  operation,  since  the  sutures  cannot  be  removed,  and  ought  to 
resist  dissolution  for  some  time  (p.  204). 

This  operation  does  not  interfere  with  coition,  since  it  only  forms  a 
double  vagina;  but  in  case  childbirth  should  take  place  the  artificial 
septum  would  probably  be  destroyed.  The  operation  is,  therefore, 
particularly  indicated  after  the  menopause. 

In  women  who  are  beyond  the  child-bearing  period,  or  who  are 
absolutely  incurable  by  any  of  the  conservative  methods,  Munde'3 
has  resorted  to  the  high  amputation  of  the  cervix  by  making  a  circu- 
lar incision  around  the  cervix,  pushing  up  the  vaginal  walls  with 
finger  and  seal  pel -handle,  and  removing  the  bladder  and  the  perito- 
neum of  Douglas's  pouch  from  the  seat  of  operation.  Having  thus 
exposed  an  inch  to  an  inch  and  a  half  of  the  raw  cervix,  he  ampu- 
tated it  with  the  galvano-caustic  wire.  Passing  a  tent  of  iodoform 
gauze  into  the  cervix  to  prevent  the  closure  of  that  canal,  he  returned 
the  uterus  into  the  pelvic  cavity  and  packed  the  vagina  with  iodoform 
gauze.  The  cicatricial  contraction  of  the  vaginal  vault  resulted  in 
forming  so  firm  an  attachment  that  the  uterus  was  retained  in  its 
normal  position. 

Freund's  operation 4  is  mentioned  only  in  order  to  warn  against  it. 
It  consists  in  the  insertion  of  three  or  four  silver  wire  rings  under  the 
mucous  membrane  of  the  vagina,  one  below  the  other.  It  can  only 
be  used  in  old  women,  since  it  excludes  connection.  It  is  said  to  be 
so  painless  that  it  can  be  performed  without  anesthesia,  but  it  is  decep- 
tive, since  the  wires  soon  cause  suppuration  and  come  out. 

Vaginal  Hysterectomy, — In  those  very  rare  cases  of  prolapse  that 
have  resisted  all  other  methods,  the  extirpation  of  the  prolapsed  uterus 
is  justifiable.  In  performing  it  a  considerable  part  of  the  vagina  must 
also  be  removed.  The  modus  operandi  by  Fritsch's  method 5  is  the 
following :  The  patient  is  in  the  breech-back  position  (p.  368).  The 

1  Fanny  Berlin  of  Boston,  Amer.  Jour.  Obst.,  Oct.,  1881,  vol.  xiv.  p.  870. 

2  H.  C.  Coe,  Annals  of  Gynecol.  and  Pcediatry,  May,  1890,  vol.  iii.  p.  374. 

3  P.  F.  Munde",  Amer.  Jour.  Obst.,  Nov.,  1891,  vol.  xxiv.  p.  1291. 

4  H.  W.  Freund,  Centralbl.  f.  Gyndk.,  1893,  No.  47,  vol.  xvii.  p.  1081. 

5  Asch,  Archivfiir  Gynakologie,  1889,  vol.  xxxv.  p.  206. 


DISEASES   OF  THE   UTERUS.  459 

base  of  the  tumor  is  constricted  with  a  rubber  tube  in  order  to  pre- 
vent hemorrhage.  The  vaginal  portion  is  seized  with  a  volsella,  and 
pulled  well  upward  (Fig.  255).  Xow  an  incision  is  made  on  the 
posterior  vaginal  wall,  between  the  middle  and  upper  third,  in  the 
shape  of  an  acute  angle,  the  top  of  which  is  situated  in  the  median 
line  and  points  backward  toward  the  posterior  commissure.  This 
incision  opens  Douglas's  pouch.  The  next  step  is  to  stitch  the  peri- 
toneum to  the  posterior  vaginal  wall.  The  fundus  uteri  is  easily 


FIG.  255. 


Fritsch's  Hysterectomy  for  Prolapsed  Uterus. 

pulled  out,  and  a  sponge  with  attached  thread  placed  so  as  to  retain 
the  intestines.  Now  the  broad  ligaments  are  gradually  tied  in  sections, 
proceeding  from  their  upper  end  to  their  base,  with  a  half-sharp 
aneurism-needle  bent  to  the  side  (Fig.  269,  p.  487)  and  threaded  with 
stout  silk.  If  possible  the  tubes  and  ovaries  are  comprised  in  the  parts 
to  be  removed.  As  soon  as  a  section  is  tied,  it  is  cut  between  the  liga- 
ture and  the  uterus.  Next,  the  vaginal  portion  is  carried  far  down, 
and  an  incision  similar  to  that  on  the  posterior  wall  is  made  on  the 
anterior  wall  of  the  vagina  (Fig.  256),  but  only  through  the  vaginal 
wall,  without  entering  the  bladder.  This  triangle  is  separated  from 
the  bladder,  partly  with  blunt  instruments  and  partly  with  the  knife, 
and  the  edges  of  the  wound  united  by  means  of  transverse  sutures. 
By  pulling  the  fundus  uteri  again  forward  and  upward,  the  line  where 


460 


DISEASES  OF  WOMEN. 


the  peritoneum  passes  from  the  bladder  to  the  anterior  surface  of  the 
uterus  is  brought  into  view  and  incised  ;  and  then  the  posterior  wall 
of  the  bladder  is  dissected  from  the  uterus  from  above  and  from  below. 
Spurting  vessels  are  caught  and  later  tied.  Finally,  the  peritoneum 
of  the  bladder  is  stitched  to  the  rest  of  the  anterior  vaginal  wall,  or 
rather  the  lateral  walls,  which  have  been  stitched  together  in  the 


Fritsch's  Hysterectomy  for  Prolapsus  Uteri. , 

median  line,  and  the  stumps  of  the  broad  ligaments  are  also  fastened 
to  the  vagina. 

G.  Elevation. 

The  uterus  may  be  raised  by  tumors  in  the  pelvis,  or  ascend  by  its 
own  size,  as  in  pregnancy,  or  be  pulled  up  by  contracting  inflamma- 
tory adhesions.  Sometimes  the  whole  vaginal  portion  disappears. 

H.  Inversion. 

Inversion  consists  in  a  turning  inside  out  of  the  uterus  (Fig.  257). 
Jt  may  be  total  or  partial.  As  a  rule,  the  inversion  begins  as  an 


DISEASES   OF  THE   UTERUS. 


461 


indentation  at  the  fundus,  but  it  may  also  begin  in  the  cervix,  subse- 
quently dragging  down  the  body.  We  distinguish  three  degrees.  In 
the  first  degree  the  inverted  part  is  found  inside  of  the  uterus  ;  in  the 
second,  it  has  descended  into  the  vagina;  and  in  the  third  it  is 
combined  with  prolapse  and  hangs  outside  of  the  vulva. 

Inversion   comes   under   observation   at   three   different   periods: 


Section  of  the  Second  Degree  of  Inversion  of  Uterus  (Crosse):  a,  vagina:  b,  fundus  uteri;  c,c, 
angles  of  inflection ;  c,c,  d,d,  extent  of  nninverted  cervix  ;  e,  vaginal  wall ;  /,  the  perito- 
neal cul-de-sac  of  the  inverted  uterus  :  g,g,  Fallopian  tubes  passing  down  into  the  in- 
verted uterus ;  h,h,  ovaries ;  i,i,  broad  ligaments ;  k,k,  round  ligaments. 

immediately  after  the  occurrence  of  the  accident,  especially  during  or 
immediately  after  childbirth,  in  regard  to  which  the  reader  is  referred 
to  works  on  obstetrics ;  about  six  weeks  after  labor,  when  hemorrhage 
or  other  symptoms  induce  the  patient  to  seek  advice;  and,  finally,  a 
long  time,  often  many  years,  after  its  formation. 

Etiology. — Inversion  is  a  very  rare  accident,  only  one  case  having 
occurred  in  about  1 50,000  cases  of  delivery.  Thue  most  common  cause 
is  childbirth,  especially  if  it  takes  place  in  the  erect  posture,  if  the 
cord  is  too  short,  if  the  accoucheur  or  the  midwife  pulls  on  it  in  order 
to  remove  the  placenta,  and  if  it  is  inserted  on  the  fuudus.  But  the 
inversion  may  also  take  place  some  time  after  the  birth  of  the  child, 
especially  at  the  time  of  getting  up,  although  the  lying-in  period  lias 
been  normal  in  every  respect.  Laceration  of  the  cervix  may  predis- 
pose to  it.  After  abortion  it  is  still  rarer  than  after  childbirth.  It 
has  also  been  observed  in  connection  with  a  vesicular  mole. 

Secondly,  a  tumor  of  the  fundus  uteri,  especially  a  fibroid,  being 
expelled,  drags  the  uterus  along. 

Thirdly,  inversion  may  occur  when  the  uterus  is  enlarged  and  its  tis- 
sue softened,  independently  of  pregnancy  and  the  presence  of  a  tumor. 

Where  there  is  no  tumor,  the  mechanism  is  the  following :  A  part 
of  the  uterine  wall,  most  frequently  the  placental  site,  becomes  par- 
alyzed and  sinks  down,  while  the  surrounding  parts  contract  above  it. 


462  DISEASES  OF  WOMEN. 

Thus  a  kind  of  peristaltic  movement  is  set  up,  proceeding  from  above 
downward.  But  if  the  inversion  begins  at  the  cervix,  the  movement 
takes  place  in  the  opposite  direction,  from  below  upward. 

Pathological  Anatomy. — The  inverted  part  of  the  uterus  may  only 
be  a  cup-shaped  depression  near  the  fundus ;  or  it  may  form  a  pear- 
shaped  body,  the  lower  end  of  which  does  not  pass  the  internal  os ; 
or  it  may  hang  in  the  vagina,  the  pedicle  being  surrounded  by  a  ring 
formed  by  the  cervix ;  or  the  whole  cervix  and  part  of  the  vagina 
may  have  become  inverted  in  their  turn.  If  the  tumor  is  yet  retained 
in  the  body  of  the  uterus,  it  is  covered  with  a  dark-red,  swollen 
mucous  membrane  that  easily  bleeds.  On  the  lower  end  may  be 
seen  two  minute  openings,  admitting  a  bristle,  which  are  the  uterine 
apertures  of  the  Fallopian  tubes. 

When  the  inverted  part  lies  in  the  vagina,  its  mucous  membrane 
sometimes  loses  its  glands  and  becomes  like  that  of  the  vagina.  If 
it  is  expelled  outside  of  the  patient's  body,  it  often  ulcerates  and 
cicatrizes,  which  gives  it  a  cutaneous  appearance. 

Seen  from  the  peritoneal  cavity,  the  inverted  uterus  forms  a  funnel- 
shaped  depression,  into  which  descend  the  Fallopian  tubes,  the  round 
ligaments,  and  sometimes  the  ovaries.  In  old  cases  this  funnel  may 
be  impervious,  the  contiguous  sides  of  the  peritoneum  having  grown 
together. 

Symptoms. — In  most  cases  the  inversion  of  the  uterus,  taking  place 
suddenly  in  connection  with  childbirth,  is  accompanied  by  marked 
symptoms — hemorrhage,  pain,  collapse,  and  the  formation  of  the 
characteristic  tumor  in  the  vagina  and  the  funnel  above  the  symphy- 
sis.  But  in  exceptional  cases  all  alarming  symptoms  may  be  absent.1 

In  the  subacute  and  chronic  forms  the  chief  symptom  is  again  hem- 
orrhage, which  may  undermine  the  constitution  by  its  frequent  recur- 
rence or  profuseness,  to  which  are  added  leucorrhea,  dragging  pain, 
difficulty  in  walking,  and  different  nervous  reflexes.  Physical  exam- 
ination reveals  the  peculiar  shape  of  the  fuudus  and  the  presence  of 
a  tumor  in  the  vagina. 

Diagnosis. — The  diagnosis  of  inversion,  apart  from  obstetric  cases, 
may  be  very  difficult,  and  is  of  the  utmost  importance  in  regard  to 
treatment.  Only  great  carelessness  could  fail  to  distinguish  common 
prolapse  and  hypertrophy  of  the  cervix  from  inversion,  the  distinctive 
feature  being  the  presence  of  the  os  uteri  at  the  lower  end,  through 
which  the  sound  can  be  entered  more  or  lass  deeply.  The  tumor 
in  prolapse  is  broader  at  the  upper  end  than  at  the  lower,  whereas 
the  opposite  is  the  case  with  an  inverted  uterus.  A  catheter  goes 
downward  into  the  cystocele  accompanying  prolapse,  but  upward  in 
case  of  inverted  uterus.  A  polypus  may  offer  entirely  similar  symp- 

1  John  C.  Reeve  has  contributed  a  paper  full  of  instruction,  on  Inversion,  in  Gyn. 
Trans.,  1884,  vol.  Lx.  p.  69. 


DISEASES  OF  THE   UTERUS.  463 

toms,  and  a  tumor  of  the  same  shape  and  appearance  may  be  found 
in  the  same  place ;  but  if  it  is  a  polypus  the  sound  can  be  introduced 
to  the  depth  of  a  normal  uterus  or  deeper  between  the  tumor  and  the 
cervix,  while  in  inversion  it  is  soon  arrested  at  the  place  where  the 
uterus  is  inflected.  Bimanual  examination  shows,  when  we  have  to 
do  with  a  polypus,  that  the  uterus  is  in  its  place.  If,  especially  in 
stout  women,  the  uterus  cannot  be  felt  through  the  abdominal  wall, 
recourse  may  be  had  to  rectal  examination  (p.  142).  A  catheter  held 
in  the  bladder  may  help  to  settle  the  diagnosis,  and  if  there  is  any 
doubt  the  urethra  should  be  dilated  (p.  142),  and  the  index-finger 
introduced  into  the  bladder,  from  which  it  can  palpate  the  uterus. 
If  it  is  a  case  of  inversion,  these  same  manipulations  will  show  that 
the  uterine  body  is  not  in  its  place,  and  that  instead  there  is  a  funnel- 
shaped  depression.  It  is  also  claimed  that  if  a  needle  is  thrust  into  the 
tumor,  it  will  cause  pain  in  an  inverted  uterus,  but  not  in  a  polypus. 

If  we  have  a  fibroid  as  cause  of  the  inversion,  and  it  is  yet  in  the 
uterus,  the  differential  diagnosis  may  be  particularly  difficult.  Under 
such  circumstances  the  sound  enters  to  its  usual  depth,  but  the  depres- 
sion of  the  fundus  can  be  made  out  by  the  above-named  means. 

If  the  fibroid  has  dragged  the  uterus  down  with  it,  the  sound  does 
not  enter,  but  it  becomes  necessary  to  distinguish  which  part  of  the 
tumor  is  the  uterus  proper  and  which  the  fibroid.  In  this  respect  the 
fact  that  the  fibroid  is  harder,  nodulated,  and  painless  on  acupuncture 
is  an  aid  to  diagnosis. 

If  adhesion  takes  place  between  the  pedicle  of  a  polypus  and  the 
cervix,  the  sound  cannot  enter,  but  then  the  uterus  is  found  in  its 
normal  place  and  of  normal  shape. 

A  similar  condition  obtains  when  it  is  a  so-called  hollow  polypus*  an 
exceedingly  rare  disease,  the  pathology  of  which  is  not  quite  settled. 
There  is  found  a  tumor  in  the  vagina  as  in  common  polypus  and  inver- 
sion, but  the  sound  cannot  be  made  to  enter  anywhere  between  the 
pedicle  and  the  cervix  without  violence.  This  tumor  is  soft  and  con- 
tains fluid,  which  distinguishes  it  from  a  fibroid  polypus  adherent  to 
the  cervix.  One  theory  is  that  a  plastic  deposit  is  produced  on  the 
endometrium,  and  that  blood  or  other  fluid  accumulates  between  it  and 
the  uterine  wall,  lifts  it  up,  and  forms  the  polypoid  tumor  that  is  ex- 
pelled through  the  os.  Another  theory  is  that  it  is  the  endometrium 
itself  that  becomes  detached  and  peeled  off  down  to  the  cervix.  A 
third  possibility — and,  in  my  opinion,  more  likely  than  either  of  the 
others — would  be  that  a  common  fibroid  polypus  contracts  adhesions 
with  the  cervix;  that  its  interior  becomes  myxomatous  and  melts, 
forming  a  cyst  in  the  way  we  shall  see  in  studying  the  formation  of 
fibro-cysts,  which  cyst  later  communicates  with  the  uterine  cavity  by 
absorption  of  the  partition.  However  this  may  be,  the  fact  is  that 
1  Sussdorff,  Jour,  Obst.,  1877,  vol.  x.  p.  553. 


464  DISEASES  OF  WOMEN. 

we  have  a  sac  filled  with  fluid  protruding  through  and  attached  to  the 
cervix.  The  sound  does  not  enter,  but  the  tumor  is  softer  than  an 
inverted  uterus.  By  pulling  on  it,  the  relations  between  it  and  the 
cervix  remain  unchanged,  whereas  in  inversion  the  cervix  becomes 
more  inverted  or  disappears  altogether.  Examination  through  the 
rectum  practised  while  this  traction  is  made  will  show  that  the  ute- 
rus is  in  its  place  and  has  its  normal  shape.  If  the  sound  is  made 
forcibly  to  penetrate  the  obstacle  round  the  pedicle,  it  enters  a  cavity 
of  the  normal  depth  of  the  uterus. 

Prognosis. — Inversion  of  the  uterus  is  a  very  dangerous  condition, 
accompanied  by  great  mortality.  The  total  mortality  is  20  per  cent., 
but  it  is  far  less  in  chronic  cases  than  in  obstetric  practice.  Spon- 
taneous replacement  is  possible,  but  rare.  Another  spontaneous  cure, 
accompanied  by  the  dangers  of  septicemia,  is  occasionally  brought 
about  by  gangrene  of  the  inverted  mass.  Most  of  the  measures 
adopted  for  the  cure  of  inversion  are  more  or  less  dangerous. 

Treatment. — The  measures  to  be  taken  for  the  inversion  occurring 
during  labor  are  taught  in  works  on  obstetrics.  Here  we  treat  only 
of  more  or  less  old  cases.  Experience  has  shown  that  the  best  treat- 
ment is  that  with  elastic  pressure.  The  vagina  is  disinfected  and 
Aveling's  repositor  applied.  It  is  made  of  hard  rubber,  aud  consists 
of  a  little  cup  which  presses  on  the  inverted  fundus,  and  an  S-shaped 
rod,  which  protrudes  from  the  vulva  and  carries  pressure  made  at  its 
lower  end  upward  in  the  direction  of  the  pelvic  axis.  To  the  lower 
end  are  attached  four  elastic  tapes,  which  are  drawn  through  rings 
fastened  to  a  belly-binder.  Two  of  the  tapes  are  brought  forward 
and  two  backward,  and  they  enable  us  to  give  the  rod  the  desired 
direction.  A  pressure  of  two  and  a  half  pounds  is  sufficient.  This 
method  is  safe,  hardly  ever  fails,  and  leads  to  replacement  in  a  short 
time — from  nine  to  fifty-four  hours — by  starting  an  antiperistaltic 
movement,  so  that  the  part  forming  the  pedicle  is  first  replaced,  and 
the  fuudus  last. 

The  same  principle  of  elastic  pressure  may  be  applied  in  different 
ways.  A  soft-rubber  cup  is  attached  to  a  curved  hard-rubber  stem, 
from  the  end  of  which  tapes  go  to  rings  in  a  belt  round  the  abdomen 
(Barnes).  The  uterus  is  surrounded  with  cotton  pledgets  soaked  in 
glycerin  ;  then  a  soft-rubber  bag  is  introduced  into  the  vagina,  upon 
which  pressure  is  obtained  by  passing  a  strap  of  adhesive  plaster  from 
the  lumbar  region  over  the  genitals  to  the  umbilicus  (Thomas).  The 
common  German  way  is  to  use  the  colpeurynter,  a  large  rubber  bag 
distended  with  air  or  water ;  by  its  great  side  pressure  it  causes  con- 
siderable pain,  and  can  hardly  be  borne  for  more  than  five"  or  six 
hours  a  day,  wherefore  the  treatment  may  take  a  month  or  more. 
Between  the  applications,  the  vagina  is  treated  with  warm  disinfectant 
injections.  Another  way  that  dispenses  with  the  use  of  any  particular 


DISEASES  OF  THE   UTERUS.  4G5 

instrument,  is  to  pack  the  vagina  firmly  with  iodoform  gauze,  which 
is  renewed  every  two  or  three  days. 

During  all  these  treatments  the  patient  is  kept  in  bed,  and  if  neces- 
sary the  pain  relieved  by  hypodermic  injections  of  morphine. 

If  the  elastic  pressure  does  not  succeed,  recourse  is  had  to  one  of 
the  following  methods  of  manual  replacement,  which  are  used  on  the 
anesthetized  patient. 

Emmet  surrounded  the  tumor  with  the  fingers  of  the  left  hand  and 
pressed  at  the  base,  making  counter-pressure  through  the  abdominal 
wall  on  the  ring  in  the  peritoneum. 

Noeggerath  applied  the  thumb  and  middle  finger  to  the  horns  of 
the  uterus,  replaced  first  one  of  them,  then  the  other,  and  finally  the 
fundus ;  counter-pressure  was  made  as  in  Emmet's  method. 

Courty  introduced  two  fingers  of  the  left  hand  into  the  rectum, 
which  allows  pressure  on  the  cervical  ring  with  greater  effect,  while 
the  fingers  of  the  right  hand  press  at  the  base  of  the  tumor  in  the 
vagina. 

Tate  of  Cincinnati  dilated  the  urethra,  introduced  the  right  index-fin- 
ger into  the  bladder,  and  pressed  on  the  ring  from  this  side,  at  the  same 
time  using  the  left  index-  and  middle  finger  in  the  rectum,  as  Courty 
did,  and  applying  both  thumbs  to  the  horns  as  in  Noeggerath's  method. 

Instruments  for  replacing  the  inverted  uterus  have  been  devised  by 
White  of  Buffalo  and  Byrne  of  Brooklyn. 

If  a  partial  rein  version  is  obtained  in  any  way,  Emmet's  device,  of 
pulling  the  lips  of  the  cervix  together  over  the  still  inverted  fundus, 
and  uniting  them  with  deep  silver-wire  sutures,  may  be  followed. 
Thus  an  elastic  pressure  is  obtained  that  may  lead  to  complete 
replacement. 

The  efforts  to  reduce  the  inversion  must  be  continued  as  long  as 
possible,  say  for  half  an  hour,  different  operators  relieving  one 
another.  If  one  method  does  not  succeed,  and  her  condition  war- 
rants delay,  the  patient  should  be  given  a  few  days  rest,  and  another 
method  tried.  In  the  mean  time,  the  tumor  may  be  softened  with 
warm  vaginal  injections  and  sitz-baths. 

Conservative  Cutting  Operations.  Thomas  performed  laparatomy 
and  dilated  the  cervical  ring  with  an  instrument  like  a  glove-stretcher. 
This  method  would  probably  be  the  best  in  old  cases  in  which  adhes- 
ions have  formed  between  the  walls  of  the  internal  ring. 

Barnes  pulled  the  tumor  well  down  with  a  tape,  and  made  three 
longitudinal  incisions  in  the  cervix.  After  that  he  could  easily  replace 
the  tumor  by  manipulation. 

Amputation. — When  all  conservative  measures  fail,  the  tumor  must 
be  removed.  The  chief  danger  of  this  method  is  the  possibility  of 
the  presence  of  the  intestine  in  the  inverted  part.  An  elastic  Uyatirre 
may  be  applied  round  the  base,  and  tightened  every  day.  The  stran- 

30 


466  DISEASES  OF  WOMEN. 

gled  tumor  falls  off  in  twelve  to  eighteen  days.  Before  applying  the 
ligature  a  bed  is  made  for  it  by  burning  a  groove  with  the  thermo- 
cautery  (p.  182). 

Some  prefer  to  remove  the  mass  by  means  of  the  galvano-caustic 
wire,  or  Paquelin's  thermo-caute?'y,  which  does  away  with  the  dangers 
of  septic  infection  from  the  putrefying  tumor ;  and  if  reinversion  of 
the  stump  should  take  place,  the  cut  surface  forms  a  hollow  cone  from 
which  discharge  can  escape  into  the  vagina. 

The  tumor  may  also  be  cut  away  with  knife  and  scissors,  but  then 
silver  sutures  should  be  drawn  through  the  base  before  the  ablation, 
so  as  to  be  able  to  close  the  peritoneal  cavity.  On  each  side  one  suture 
should  be  brought  out  transversely,  so  as  to  encircle  the  lateral  blood- 
vessels, while  three  middle  sutures  bring  the  cut  surfaces  together. 

Destruction  of  the  Mucous  Membrane. — In  irreducible  cases  in  women 
near  the  climacteric,  the  dangers  of  amputation  may  sometimes  be 
avoided  by  destroying  the  mucous  membrane  and  producing  cicatri- 
zation by  means  of  potassa  cum  calce  or  the  ther mo-cautery. 

If  inversion  is  produced  by  a  fibroid,  this  must  be  removed  before  an 
attempt  is  made  to  reduce  the  inversion.  It  is  sometimes  difficult  to 
find  the  line  of  demarkation.  The  safest  is  to  make  an  incision 
over  the  end  of  the  tumor  and  enucleate  it  with  Thomas's  serrated 
scoop  (Fig.  264),  which  will  be  described  in  treating  of  fibroids. 
When  once  the  tumor  is  removed,  perhaps  parts  of  the  tissue  in  which 
it  was  imbedded  have  to  be  cut  away.  Next,  the  uterus  is  to  be  rein- 
verted  and  packed  with  iodoform  gauze. 

If  the  tumor  is  malignant,  the  whole  uterus  should  be  extirpated 
by  vaginal  hysterectomy,  as  detailed  under  Cancer  of  the  Uterus. 

If  we  have  to  deal  with  a  hollow  polypus,  it  should  'be  pulled 
down,  which  is  best  done  by  surrounding  it  with  a  noose.  If  there 
is  any  difficulty  in  applying  it,  a  sling-carrier  in  the  shape  of  a  uterine 
sound  with  a  small  crescent  at  the  end  will  easily  bring  it  up.  A  small 
incision  is  made  in  the  pedicle,  through  which  the  sound  is  passed,  and 
only  enters  to  a  depth  corresponding  to  the  size  of  the  uterus.  The 
diagnosis  thus  having  been  completed,  the  protruding  tissue  is  removed 
by  ligature,  thermo-cautery,  or  galvano-caustic  wire. 

I.  Hernia  Uteri. 

Hernia  uteri,  or  hysterocele,  is  that  displacement  of  the  uterus  in 
which  it  is  found  lying  outside  of  the  pelvis  in  a  sac  formed  by  the 
peritoneum.  The  uterus  has  been  found  in  an  inguinal  and  in  a 
crural  hernia.  Such  cases  are  extremely  rare.  They  are  nearly 
always  congenital  malformations.  (See  p.  394.) 


DISEASES  OF  THE  UTERUS.  467 

CHAPTER   XIII. 

NEOPLASMS. 
A.  Cysts  of  the  Uterus;  Adenoma  Uteri;  Mucous  Polypi ;  Myxoma. 

In  regard  to  cysts  of  the  cervix  and  o villa  of  Naboth  we  refer  to 
what  has  been  said  above  under  Lacerated  Cervix  (pp.  396  and  399) 
and  Chronic  Endometritis  (pp.  407  and  413).  These  cysts,  being 
formed  by  occluded  glands,  are  a  kind  of  adenoma. 

Cysts  of  the  corpus  uteri  are  very  rare.  Sometimes  they  are  multi- 
ple. They  are  supposed  to  owe  their  origin  to  a  detachment  of  the 
bottoms  of  uterine  glands,  or  to  be  developments  of  Gartner's  canal. 
(Compare  Vaginal  Cyst,  p.  358.) 

In  speaking  of  hyperplastic  eudometritis  (p.  408)  we  have  men- 
tioned another  kind  of  adenomas,  small  benign  tumors  formed  by  a 
conglomeration  of  hyperplastic  uterine  glands.  They  may  be  sessile 
and  do  hardly  ever  become  larger  than  a  walnut,  but  have  a  tendency 
to  become  pedunculated  and  form  so-called  glandular  polypi.  Such 
polypi  start  very  frequently  from  the  mucous  membrane  of  the  cervix, 
and  hang  out  from  the  os,  where  sometimes  they  may  acquire  so  con- 
siderable a  size  as  to  fill  the  vagina ;  but  that  is  rare.  Most  of  them 
come  under  treatment  when  they  are  not  larger  than  a  cherry,  a 
pigeon's  egg,  or  a  small  oyster.  They  are  soft,  covered  with  a  dark 
red  mucous  membrane.  They  are  full  of  cavities,  the  contents  of 
which  are  thin  or  thick,  clear  or  dark. 

Sometimes  the  polypi  are  formed  of  myxomatous  tissue  consisting 
of  a  delicate  fibrous  network,  with  slight  thickening  at  the  points 
of  intersection,  and  a  hyaline  or  finely  granular  mucoid  basis  sub- 
stance in  the  meshes,  in  which  we  find  imbedded  single  or  multiple 
granular  corpuscles.  Glandular  formations  are  rare  or  absent.1 

The  name  "  adenoma  "  is  also  taken  in  a  narrower  sense,  and  used 
to  designate  a  tumor  formed  by  an  exuberant  growth  of  utricular 
glands,  while  the  connective  tissue  between  the  epithelial  tracts  is 
extremely  scanty  and  fibrous,  only  a  small  number  of  medullary  cor- 
puscles being  present. 

In  contradistinction  from  this  benign  adenoma,  some  authors  speak 
of  a  malignant  adenoma,  which  is  only  the  first  stage  of  carcinoma. 
The  microscopical  appearance  which  characterizes  it  is  described  as 
follows :  The  gland-spaces  are  very  much  enlarged,  very  irregular, 
and  are  frequently  seen  to  break  through  into  other  gland-spaces.  The 
columnar  epithelial  cells  are  attached  to  the  stroma,  as  a  rule,  and 
they  are  often  converted  into  cuboidal  or  even  squamous  cells.  These 

1  Louis  Heitzmann,  "  The  Differential  Diagnosis  between  Fungous  Endometritis 
and  Tumors  of  the  Mucosa  of  the  Uterus,"  Amer.  Jour.  Obst.,  Sept.,  1887,  vol.  xx. 
p.  897. 


468  DISEASES  OF   WOMEN. 

cells  are  frequently  seen  filling  up  a  gland-space.  They,  however, 
never  infiltrate  the  interstitial  or  stroraa  tissue.  The  neoplasm  ex- 
tends to,  and  appears  to  progressively  destroy,  the  muscular  wall  by 
atrophy  or,  perhaps,  fatty  degeneration.  It  persistently  progresses  as 
an  atypical,  glandular,  epithelial  type  of  disease.1 

Symptoms. — Mucous  polypi  cause  hemorrhage,  leucorrhea,  and 
sometimes  pelvic  pain,  backache,  or  dyspareunia.  When  situated 
above  the  internal  os,  they  may  work  like  a  ball- valve  and  cause 
great  dysmenorrhea. 

The  treatment  of  mucous  polypi  and  benign  adenoma  must  begin 
with  the  removal  of  the  growths.  In  the  interior  of  the  uterus  this 
is  done  with  the  curette  (p.  176).  From  the  cervix  they  may  be  torn 
off  by  seizing  them  with  forceps  and  turning  the  instrument  until  the 
pedicle  is  severed  (torsion).  Or  they  may  be  cut  off  with  scissors, 
but  then  it  is  well  to  have  a  therrno-cautery  in  readiness,  as  there  may 
be  some  hemorrhage.  They  may  also  be  removed  with  the  galvano- 
caustic  wire  or  a  simple  cold  wire  ecraseur.2 

After  removal  of  the  growth  the  accompanying  chronic  endome- 
tritis  should  be  treated  as  described  above  (pp.  412—415). 

Malignant  adenoma  is  an  indication  for  speedy  vaginal  hysterec- 
tomy. 

B.   Cavernous  Angioma  of  the  Uterus. 

This  neoplasm  is  very  rare.  It  consists  of  a  tumor  formed  of 
ectatic  veins  filled  with  blood. 

Pathological  Anatomy. — The  tumor  varies  in  size  from  a  hickory 
nut  to  an  English  walnut.  It  is  situated  in  the  muscular  coat  and 
covered  with  the  endometrium  and  the  peritoneum.  The  inner  sur- 
face is  nodular.  The  tumor  is  either  spongy  or  harder  than  the  sur- 
rounding uterine  tissue.  On  incision  the  cut  surface  is  covered  with 
dark,  fluid  blood,  and  after  this  has  been  removed  a  delicate  frame- 
work with  thicker  nodules  appears.  The  cavities  of  the  framework, 
which  differ  in  size  and  intercommunicate,  are  filled  with  fluid 
blood.  The  framework  consists  of  smooth  muscle-fibers  covered 
with  fibrillae  of  connective  tissue  with  an  endothelium.  In  some 
places  are  seen  outgrowths  of  connective  tissue  forming  papillae. 
The  cavities  of  the  tumor  communicate  with  the  veins  of  the 
neighborhood. 

Etiology. — The  cause  of  the  formation  of  uterine  angioma  is  un- 
known. Perhaps  it  sometimes  originates  in  a  subiuvolution  of  the 
placental  site. 

1  H.  D.  Beyea,  Amer.  Jour.  ObsL,  Feb.,  1896,  vol.  xxxiii.  p.  200. 

2  Fibrinous  polypi  are  pedunenlated  growths  formed  by  layers  of  fibrin  deposited 
over  a  remnant  of  the  after-birth  left  in  the  interior  of  the  womb  after  childbirth  or 
abortion.     The  symptoms  and  treatment  are  like  those  of  intra-uterine  glandular 
polypi. 


DISEASES  OF  THE  UTERUS.  469 

Symptoms. — This  kind  of  tumor  gives  rise  to  recurrent  and  pro- 
fuse hemorrhage. 

The  diagnosis  can  only  be  made  by  microscopical  examination  of 
the  scrapings  obtained  by  curetting. 

Treatment. — Since  this  neoplasm  may  occupy  the  whole  thickness 
of  the  uterine  wall,  curetting  may  lead  to  perforation. 

In  the  only  case  observed  clinically,  the  uterus  was  removed  by 
vaginal  hysterectomy.1 

C.  Uterine  Fibroids ;  Fibroid  Polypi ;  Fibro-cysts  of  the  Uterus. 

Fibroid  tumors,  or  fibroids  of  the  uterus,  fibromata,  are  more  exactly 
called  myomata — i.  e.  muscular  tumors — or  myofibromata,  or  fibro- 
myomata — names  denoting  a  mixture  of  muscular  and  fibrous  connec- 
tive tissue  in  their  composition. 

Pathological  Anatomy. — Fibroids  are  so  common  that  they  are 
found  in  the  body  of  one  out  of  every  five  women  over  thirty-five 
years  of  age.  They  are  globular  tumors  composed  of  several  nodules, 
and  may  attain  enormous  dimensions,  weighing  up  to  140  pounds. 
They  are  mostly  harder  than  normal  uterine  tissue,  but  may  be  so 
soft  that  they  impart  a  sensation  which  cannot  be  distinguished  from 
fluctuation.  On  the  cut  surface  they  appear  white  or  pinkish,  show 
an  irregular  concentric  arrangement  of  the  fibers  around  different 
<;entres,  and  bulge  out  beyond  the  surrounding  parts.  In  most  cases 
the  tumor  is  separated  from  the  uterine  tissue  by  a  layer  of  loose 
connective  tissue,  the  so-called  capsule,  so  that  it  is  easily  shelled  out, 
but  often  this  capsule  is  incomplete,  and  the  tumor  is  a  direct  continua- 
tion of  the  surrounding  muscular  wall.  As  a  rule,  the  substance  is 
compact  and  contains  less  fluid  than  the  surrounding  tissue,  but  some- 
times it  is  full  of  dilated  arteries,  veins,  or  lymph-spaces  (cavernous 
myoma,  myoma  teleangiectodes  and  lymphangiectodes).  Nerves  can 
be  followed  into  the  interior.  The  uterus  grows  with  the  tumor, 
so  that  its  cavity  becomes  larger;  as  a  rule,  the  muscular  tissue 
becomes  hyperplastic,  and  numerous  blood-vessels  are  developed  in 
it.  But  in  exceptional  cases,  on  the  contrary,  the  normal  muscular 
tissue  nearly  disappears,  and  the  uterus  forms  only  a  bag  filled  with 
<3alcified  tumors. 

Fibroids  may  be  developed  in  the  body  or  in  the  neck  of  the  womb, 
but  the  cervical  are  much  rarer  than  the  corporeal.  In  non-pregnant 
women  only  5  per  cent,  are  situated  in  the  cervix ;  in  pregnant  women 
20  per  cent,  have  this  situation,  the  relative  frequency  in  the  state  of 
gravidity  being  due  to  the  fact  that  cervical  fibroids  are  likely  to 
cause  serious  complications  of  pregnancy  and  childbirth,  which  bring 
the  patients  under  medical  observation. 

1  H.  J.  Boldt,  Amer.  Jour.  Obst.,  Dec.,  1893,  vol.  xxviii.  pp.  834-846.  Klob,  Patho- 
Jogische  Anatomie  der  weiblichen  Sexualorgane,  Wien,  1864,  p.  173. 


470 


DISEASES  OF  WOMEN. 


They  are  either  sessile  or  pedunculated,  and  the  latter  may  again 
either  hang  from  the  cervix  and  develop  into  the  vagina,  or  spring 
from  the  interior  of  the  corpus  or  fundus ;  or  they  may  spring  from 
the  outer  surface  of  the  corpus  and  fundus  and  develop  into  the  peri- 


FIG.  258. 


Transition  from  Imbedded  to  Pedunculated  Uterine  Fibroid.    Smooth  right  end  free,  the 
remainder  imbedded.1 

toneal  cavity.  Those  which  spring  from  the  cervix  and  the  uterus 
proper  and  are  covered  with  mucous  membrane  are  called  fibroid  polypi 
(compare  glandular  and  fibrinous  polypi,  pp.  408  and  467,  468),  the 
word  "  polypus  "  being  used  as  a  general  term  for  any  pedunculated 
tumor  attached  to  the  mucous  membrane  of  the  uterus. 

Sometimes  a  fibroid  may  be  partly  imbedded  in  the  uterine  wall 
and  partly  form  a  polypus,  thus  forming  a  transition  from  a  sessile  to 
a  pedunculated  tumor  (Fig.  258). 

FIG.  259. 


Pednnculated  Submucous  Fibrous  Tumor  (fibroid  polypus)  enclosed  in  Uterus  (Cruveilhier) : 
F,  fundus  of  uterus ;  O,O,  ovaries ;  L,L,  round  ligaments :  C,  cervix ;  V,  vagina;  P,  polypus. 

Fibroids  are  called  submucous  (Fig.  259)  when  a  part  of  them 
is  only  covered  with  mucous  membrane;  subperitoneal  (Fig.  260) 
if  they  are  partly  situated  immediately  under  the  peritoneum; 
and  interstitial  or  intramural  (Figv  261),  if  they  are  surrounded  by 

1  Specimen  from  my  operation  on  Mrs.  S.,  March  24,  1894. 


DISEASES  OF  THE   UTERUS.  471 

a  layer  of  muscular   tissue.     This   latter  variety   has  a  tendency 


FIG.  260. 


Pedunculated  Subperitoneal  Fibroid  (Hofmeyer). 

to  work  its  way  outward  or  inward,  so  as  to   pass  into  one  of 

FIG.  261. 


Intramural  Fibroid  (Gusserow). 

the  two  other  varieties,  and  may  even  become  pediculate. 


472 


DISEASES  OF  WOMEN. 


Sometimes  there  is  only  a  single  tumor,  but  quite  frequently 
fibroids  are  multiple.  In  the  latter  case  the  uterus  with  its  tu- 
mors may  form  a  mass  of  fantastic  shape,  often  reminding  one 
of  certain  forms  of  cactuses  (Fig.  262). 


FIG.  262. 


Large  Cactus-shaped  Uterus  full  of  Fibroids.' 

If  the  fibroid  is  developed  in  the  infravaginal  part  of  the  cervix, 
it  may  form  a  polypus  attached  to  one  of  the  lips,  but  from  the  upper 
part  it  may  develop  upward  into  the  wall  of  the  body  or  into  its 
cavity  or  into  the  connective  tissue  of  the  parametrium,  the  broad 
ligaments,  and  the  pelvis  in  general,  separating  the  layers  of  the 
mesorectum. 

Microscopical  examination  shows  that  fibroids  originate  from  round 
cells  surrounding  capillaries  which  are  undergoing  obliteration.  The 
well-developed  tumor  consists  of  uustriped  muscle-fibers,  mixed  with 
more  or  less  fibrous  connective  tissue  and  fusiform  cells. 

Fibroids  are  not  so  apt  to  be  bound  to  the  peritoneum  of  the 
abdominal  wall  or  other  organs  as  ovarian  cysts,  but  if  they  do  form 
such  adhesions,  these  are  often  broad  and  contain  very  large  blood- 
vessels ;  so  much  so  that  the  tumor  to  a  great  extent  derives  its  nour- 
ishment from  the  adhesions;  nay,  in  course  of  time  it  may  be  severed 
altogether  from  the  uterus,  and  be  found  attached  exclusively  to  an- 
other part  of  the  abdomen.  Such  pediculate  tumors  may  even  be 
torn  off  from  the  uterus  and  lie  loose  in  the  abdomen  as  necrobiotic 
masses,  without  forming  new  adhesions.  Fibroids  are  very  fre- 
quently accompanied  by  local  peritonitis,  and  may  also  cause  cellu- 

1  Specimen  from  my  operation  on  Miss  B.  M.,  in  St.  Mark's  Hospital,  March 
13,  1894. 


DISEASES  OF  THE   UTERUS.  473 

litis.  They  are  often  the  cause  of  ascites,  usually  serous,  sometimes 
chylous,  and  rarely  bloody. 

Fibroids  are  apt  to  undergo  changes  in  their  constituent  elements. 
Some  of  them  soften  and  swell  at  each  menstruation,  and  if  they  are 
pedunculated  the  tumor  at  that  time  may  be  driven  out  through  the 
cervical  canal  and  appear  in  the  vagina.  After  the  menstrual  period 
the  swelling  subsides,  and  the  tumor  recedes  again  into  the  interior 
of  the  womb,  forming  what  is  called  an  intermittent  polypus. 

A  similar  softening  and  swelling  take  place  on  a  larger  scale  during 
pregnancy,  but,  on  the  other  hand,  the  tumor  partakes  of  the  general 
involution  after  the  birth  of  the  child,  and  may  disappear  entirely. 
Such  disappearance  has  also  been  observed  after  inflammation  and 
under  circumstances  where  no  simultaneous  process  could  be  sup- 
posed to  be  the  cause.1  And  quite  frequently  fibroids  remain  of 
small  dimensions  and  give  rise  to  no  symptoms  during  the  bearer's 
whole  life. 

After  the  menopause  fibroids,  as  a  rule,  become  smaller  and  harder, 
but  they  may  continue  growing.  Even  apart  from  menstruation  and 
pregnancy  fibroids  are  apt  to  become  edematous.  Sometimes  tnyxo- 
matous  tissue  is  found  in  their  interior. 

Cysts  may  be  developed  either  by  simple  accumulation  of  serum  in 
the  meshes  of  the  tumor,  or  by  resorptiou  of  myxoid  tissue,  or  by 
dilatation  of  lymph-spaces.  The  latter  kind  has  an  endothelial  lin- 
ing.2 Often  these  cysts  first  appear  spread  as  small  hollows,  so-called 
geodes,  throughout  a  fibroid,  but  subsequently  the  intervening  tissue 
is  absorbed,  and  finally  one  large  cyst  is  formed.  Such  cysts  increase 
rapidly  in  size,  and  may  become  very  large,  twenty  quarts  having 
been  evacuated  from  one. 

The  fluid  contained  in  fibro-cysts,  as  might  be  expected  from  their 
different  nature,  differs  very  much.  Sometimes  it  coagulates  by 
exposure  to  the  air,  and  more  frequently  it  is  a  serous,  non-coagulat- 
ing fluid.  In  small  cysts  it  is  citrine,  viscid,  or  serous,  but  in  larger 
cysts  it  contains  more  or  less  blood  and  becomes  yellow,  bloody,  dark 
brown,  or  chocolate-colored.  Sometimes  the  contents  are  purulent. 
The  fluid  is  alkaline,  and  coagulates  entirely  on  boiling  and  with 
acids.  It  contains  always  much  albumin,  and  sometimes  fibrin. 
The  microscope  reveals  sometimes  detached  unstriped  muscle-cells 
from  the  surrounding  tissue. 

When  a  considerable  bloody  extravasation  takes  place  into  the 
cyst,  it  may  rupture,  and  the  contents  be  poured  into  the  peritoneal 
cavity. 

1  Doran,  "  On  the  Absorption  of  Fibroid  Tumors  of  the  Uterus,"  Trans.  London 
Obst.  Soc.,  1893,  p.  250. 

*  A  specimen  of  this  kind  is  described  in  detail  in  Garrigues's  Diagnom  of  Ovarian 
Cysts  by  Means  of  the  Examination  of  their  Contents,  Wm.  Wood  &  Co.,  New  York, 
1882,  pp.  60-63. 


474  DISEASES  OF  WOMEN. 

The  fibroid  may  slough,  either  spontaneously  or  after  operations 
or  after  the  use  of  ergot.  In  this  way  a  cure  may  be  effected,  but  the 
patient  may  also  succumb  to  septicemia. 

By  deposit  of  calcareous  matter  in  their  interior  fibroids  may 
become  calcified  and  form  a  stone-hard  mass.  They  may  also  un- 
dergo sarcomatous  or  carcinomatous  degeneration. 

Etiology. — The  causes  of  fibroids  are  unknown.  The  tumors  are 
developed  during  the  fruitful  age  of  the  woman.  They  are  found 
more  frequently  in  sterile  women  than  in  those  who  have  borne  chil- 
dren. Celibacy  may  perhaps  predispose  to  their  formation,  but  in 
most  cases  the  sterility  is  probably  the  effect  and  not  the  cause  of 
the  fibroid.  It  is  stated  nearly  everywhere  that  the  negro  race  is  more 
liable  to  fibroids  than  white  people,  but  of  late  this  has  been  denied 
by  an  American  physician,  who  has  had  exceptional  opportunities  for 
personal  observation  of  the  fact.1 

Symptoms. — Fibroids,  especially  polypi  and  the  submucous  variety, 
cause  menorrhagia  (p.  245)  and  metrorrhagia  (p.  247),  leucorrhea  (p. 
250),  hydrorrhea  (p.  410),  and  pain.  The  pain  may  be  located  in  the 
abdomen,  and  be  due  to  accompanying  peritonitis,  to  the  distension 
of  the  abdominal  wall,  or  to  the  weight  of  the  tumor.  By  pressure  on 
the  sacral  plexus  severe  neuralgia  may  be  caused  in  the  pelvis,  and 
shoot  down  through  the  legs.  A  polypus  that  is  being  expelled 
through  the  cervix  gives  rise  to  "  cramps"  or  labor-like  pain.  The 
circumference  of  the  abdomen  may  increase  enormously.  A  tumor 
is  felt  entering  the  vagina,  from  the  uterus,  or  imbedded  in  the 
uterine  wall,  or  extending  from  it  into  the  peritoneal  cavity  or  into 
the  broad  ligaments  or  the  pelvic  floor.  If  it  is  a  solid  fibroid,  it  is 
generally  more  or  less  hard,  globular,  nodular,  but  may  be  quite  soft, 
as  we  have  seen  in  the  anatomical  description.  If  it  is  a  fibre-cystic 
tumor  with  large  cysts,  it  is  fluctuating. 

The  presence  of  the  tumor  may  oppose  an  obstacle  to  micturition 
or  make  it  frequent.  If  it  presses  on  the  ureters,  it  may  cause  pye- 
litis  and  hydronephrosis.  By  pressing  on  the  rectum  it  may  be  the 
cause  of  constipation  and  hemorrhoids.  The  presence  of  the  tumor 
may  interfere  with  the  free  circulation  of  the  blood,  causing  edema, 
ascites,  dilatation  of  the  heart,  or  myocarditis.  It  may  push  the 
uterus  down  and  cause  prolapse  (p.  454).  If  attached  to  the  fundus, 
a  fibroid  polypus  in  descending  may  drag  the  uterus  along  and  cause 
inversion  (p.  460).  In  rare  cases  it  produces  diastasis  of  the  linea 
alba,  and  lies  partly  in  a  ventral  hernia.  By  pressure  on  the  uterine 
vessels,  fibroids  may  cause  a  sound  like  the  uterine  souffle  of  preg- 
nancy, and  in  very  rare  cases  a  thrill  like  an  aneurism. 

The  intraligamentous  variety  forms  a  tumor  in  the  iliac  fossa ;  that 
in  the  pelvic  floor  may  be  traced  to  the  cervix. 

1  Dr.  Middleton  Michel  of  Charleston,  S.  C.,  Med.  News,  Oct.  8,  1892. 


DISEASES  OF  THE  UTERUS.  47 5 

Diagnosis. — In  most  cases  the  diagnosis  is  easy,  but  it  may  be  very 
difficult  or  impossible.  From  hemorrhagic  metritis  sessile  fibroids 
differ  by  the  presence  of  a  tumor,  which  can  be  felt  imbedded  in 
the  wall.  A  polypus  in  the  vagina  is  felt  with  the  finger ;  in  the 
interior  of  the  womb  with  the  sound  or,  after  dilatation  (p.  1 54), 
with  the  finger.  One  examination,  at  least,  ought  to  be  made  at  the 
time  of  menstruation,  since  we  have  seen  that  the  so-called  intermit- 
tent polypus  at  that  time  becomes  accessible  to  touch,  and  may  be 
seen  in  a  speculum. 

In  cancer  of  the  cervix  soft  masses  can  be  scraped  oif  with  the 
nail.  There  soon  appears  a  hard  ring  around  it ;  it  ulcerates  at  an 
early  date ;  and  the  discharge  has  an  offensive  odor.  Cancer  of  the 
body  gives  rise  to  greater  pain  than  a  fibroid ;  the  constitution  suffers 
much  more  and  sooner ;  the  patient  becomes  emaciated,  the  skin  has 
an  ashy-yellowish  color,  while  those  affected  with  fibroids  preserve 
for  many  years  a  florid  hue  and  are  in  fairly  good  health.  The 
lymphatic  glands  corresponding  to  the  part  affected  with  cancer 
become  swollen.  Ascites  is  more  common  with  cancer,  and  a  bloody 
ascitic  fluid  is  nearly  always  associated  with  malignant  disease.  A 
sloughing  fibroid  polypus  may  resemble  an  epitheliomatous  growth 
of  the  cervix,  but  the  microscopical  examination  shows  an  entirely 
different  structure. 

A  fibroid  polypus  is  distinguished  from  a  glandular  by  its  hardness. 
It  may  not  be  possible  to  differentiate  it  from  a  fibrinous  polypus 
until  it  has  been  removed  and  examined  microscopically,  but  the  fact 
that  the  trouble  has  begun  after  childbirth  or  abortion  would  make  it 
likely  to  be  the  fibrinous  variety. 

A  fibroid  in  the  posterior  wall  may  from  the  vagina  feel  like  a 
retroflexion,  but  by  bimanual  examination  the  fundus  may  be  felt 
turned  forward,  or  the  direction  of  the  uterine  canal  may  be  ascer- 
tained with  the  sound,  and  the  greater  thickness  of  the  same  between 
the  sound  and  the  posterior  fornix  of  the  vagina  may  be  felt.  A 
fibroid  in  the  anterior  wall  may  be  taken  for  an  anteflexion,  but  the 
diagnosis  is  made  by  judging  of  the  thickness  of  the  wall  between  the 
sound  and  the  anterior  fornix  of  the  vagina. 

A  uterus  bicornis  may  be  taken  for  a  single  uterus  with  a  fibroid, 
but  the  contour  is  more  regular,  the  consistency  normal,  and  the  sound 
can  be  introduced  into  both  horns. 

In  regard  to  the  often  difficult  and  very  important  differential  dia- 
gnosis between  polypus  and  inversion  of  the  uterus  the  reader  is 
referred  to  what  has  been  said  above  (p.  463). 

Another  diagnostic  feature  of  the  utmost  importance  is  the  distinc- 
tion between  a  sessile  fibroid  and  pregnancy.  As  a  rule,  menstruation 
stops  in  the  latter,  while  in  the  former  it  goes  on,  or  is  even  increased 
in  regard  to  the  amount  of  the  secreted  blood  and  the  duration  of  the 


476  DISEASES  OF  WOMEN. 

discharge.  The  development  of  the  swelling  is  regular  and  more 
rapid  in  pregnancy.  Softening  of  the  cervix  and  lower  uterine 
segment,  fluctuation,  ballottement,  and  recognizable  parts  of  the  fetus 
are  felt.  The  fetal  heart  may  be  heard,  and  fetal  movements  both 
felt  and  heard.  The  mammary  and  stomachal  signs  of  pregnancy  are 
not  found  in  connection  with  fibroids.  In  hydramnion  we  have 
besides  the  history  of  pregnancy  an  open  cervical  canal,  through 
which  the  ovum  can  be  touched. 

Fibroid  tumors  may  be  combined  with  pregnancy,  and  the  detection 
of  such  a  condition  may  be  of  great  practical  importance  in  regard  to 
treatment.  A  suspicion  of  such  a  condition  should  always  be  awak- 
ened by  hemorrhages  during  pregnancy.  The  sound  is,  of  course,  not 
available.  The  physician  must  rely  on  the  history,  the  stethoscope, 
and  a  careful  palpation. 

A  small  subperitoneal  fibroid  may  form  a  tumor  somewhat  like  that 
formed  by  swollen  appendages  adherent  to  the  uterus,  but,  as  a  rule, 
the  latter  swelling  will  be  softer  and  much  more  tender,  and  the  ute- 
rine cavity  is  not  enlarged.  Accompanying  peritonitis  may,  however, 
make  a  fibroid  quite  tender,  and,  on  the  other  hand,  old  inflammatory 
masses  around  the  appendages  may  form  a  very  hard  tumor. 

Before  making  any  diagnosis  of  abdominal  tumors  the  physician 
should  be  sure  to  have  the  bowels  well  emptied  with  aperients  and 
enemata,  and  the  urine  drawn  with  a  catheter.  Otherwise  he  might 
be  deceived  by  seybala  or  a  full  bladder. 

A  pedunculated  subperitoneal  fibroid  may  be  so  like  a  solid  ovarian 
tumor  that  the  distinction  becomes  impossible,  and  the  same  holds 
good  in  regard  to  the  diagnosis  between  a  fibro-cyst  and  a  multilocular 
ovarian  cyst.  In  trying  to  differentiate  them  the  following  points 
should  be  considered.  Fibro-cysts  are  rather  rare  ;  ovarian  cysts  very 
common.  Fibro-cysts  are  hardly  found  in  women  below  thirty-five 
years  of  age ;  ovarian  cysts  are  frequent  in  young  persons.  Fibro- 
cysts  develop  more  slowly.  Patients  with  fibro-cysts  preserve  long  a 
good  general  health  and  have  a  florid  face,  while  in  those  with  a  mul- 
tilocular ovarian  cyst  the  constitution  soon  suffers.  With  a  fibro-cyst 
the  abdominal  veins  rarely  become  dilated ;  with  an  ovarian  cyst  it  is 
quite  common.  Hard  masses  are  felt  above  the  fibro-cyst ;  in  ovarian 
cysts  they  are  found  nearer  the  base  if  at  all.  A  fibro-cyst  draws  the 
uterus  up ;  an  ovarian  cyst  pushes  it  down  and  backward  or  forward. 
With  a  "fibro-cyst  the  uterine  cavity  becomes  often  considerably 
elongated;  with  an  ovarian  cyst  it  remains  of  normal  length  or  is 
only  slightly  deepened.  By  means  of  the  sound  it  may  be  possible 
to  move  the  uterus  independently  of  an  ovarian  tumor,  while  a 
fibro-cyst  follows  the  movements  of  the  uterus.  Ascites  is  more  com- 
monly found  with  fibro-cysts  than  with  ovarian  cysts.  Now-a-days 
we  avoid  aspiration  and  tapping,  but  if  for  some  reason  one  of  these 


DISEASES  OF  THE   UTERUS.  477 

operations  has  been  resorted  to,  coagulability  of  the  fluid  and  the 
presence  of  muscle-cells  in  it  militate  strongly  in  favor  of  a  fibre-cyst, 
while  the  presence  of  numerous  small  round  bodies  with  several 
shining  granules  speaks  as  strongly  in  favor  of  an  ovarian  cyst.1 

Fibro-cysts  of  the  uterus  can  only  be  distinguished  from  fibro-cysts 
of  the  ovary  by  the  circumstance  that  the  former  move  with  the  uterus, 
while  the  latter  may  be  movable  independently.  The  fluid  is 
identical. 

In  plain  ascites  there  is  a  swollen,  fluctuating  abdomen,  but  no 
tumor.  In  ascites  combined  with  a  fibroid  the  tumor  is  felt  on  dis- 
placing the  fluid.  Hematocele  and  exudative  peritonitis  are  acute 
diseases  with  a  sudden  start. 

Prognosis. — The  majority  of  fibroids  give  rise  to  no  symptoms  and 
are  harmless.  They  are  in  themselves  benign,  but  may  endanger  life 
in  different  ways.  After  the  menopause  their  development  is,  as  a 
rule,  arrested  ;  they  begin  to  shrink  and  the  patient  suffers  less ;  but, 
on  the  other  hand,  the  change  of  life  is  often  postponed  in  women 
affected  with  fibroids,  and  some  fibroids  continue  growing,  pursue  a 
more  disastrous  course  than  before,  and  frequently  become  cystic, 
calcareous,  or  have  abscesses  develop  in  them.2  A  spontaneous  cure 
may  occasionally  be  effected  by  involution  after  pregnancy  or  expul- 
sion of  a  polypus. 

Hemorrhage  rarely  becomes  directly  fatal,  but  through  the  repeated 
losses  of  blood  and  the  drain  caused  by  leucorrhea  the  constitution 
finally  suffers.  Pain,  worry,  and  disturbed  sleep  have  a  similar  effect. 
Mechanically,  the  tumor  may  cause  death  by  closing  the  ureters  or  the 
intestine.  The  heart  suffers  in  consequence  of  the  increased  work 
thrown  upon  it.  Large  tumors  press  on  lungs  and  liver,  interfering 
with  respiration  and  digestion. 

The  tumor  itself  has  some  tendency  to  sarcomatous  or  carcinomatous 
degeneration.  The  peritoneum  becomes  the  seat  of  chronic  inflam- 
mation, and  sometimes  palpillomatous  degeneration. 

In  rare  cases  a  fibroid  becomes  the  cause  of  embolism  and  paralysis. 

For  the  treatment  of  these  tumors  sometimes  operations  are  required 
that  belong  to  the  most  difficult  and  most  hazardous. 

Treatment. — In  treating  a  case  of  fibroid  tumor  of  the  uterus  the 
therapeutical  resources  at  our  command  should,  in  the  opinion  of  the 
writer,  be  considered  in  the  following  order : 
Cut  off  polypi ; 

Tie  and  cut  pedunculated  subperitoneal  tumors ; 
Lift  tumor  ; 
Hemostatic  and  anticatarrhal  remedies ; 

1  Exceptions  are  treated  of  in  my  above-named  wock  on  Ovarian  Cyst*,  pp.  63-i>7. 
*  Joseph  Taber  Johnson  of  Washington,  D.  C.,  "Growth  of  Fibroids  after  the 
Menopause,"  Amer.  Jour.  Obst.,  Dec.,  1891,  vol.  xxiv.,  p.  1420. 


478  DISEASES  OF  WOMEN. 

Galvauo-chemical  cauterization ; 

Curetting ; 

Vaginal  enucleation ; 

Oophorectomy ; 

Ligation  of  ovarian  and  uterine  arteries ; 

Total  extirpation  of  uterus ; 
Supravaginal  amputation — 

(a)  with  retroperitoneal  treatment  of  pedicle ; 

(6)  with  extraperitoneal  fixation  of  the  stump ; 
Abdominal  euucleation — 

(a)  from  broad  ligament ; 

(6)  from  pelvic  floor; 

(c)  from  uterine  W7all. 

For  a  polypus  there  is  no  other  treatment  than  to  remove  it  as  soon 
as  possible.  If  it  lies  in  the  vagina,  this  is  a  very  simple  matter. 
The  anesthetized  patient  is  placed  in  the  dorsal  position,  the  legs  fast- 
ened with  Robb's  leg-holder  (p.  197),  the  vagina  disinfected,  the  tumor 
brought  into  view  with  speculum  and  retractors,  the  cervix  dilated 
with  a  steel  dilator,  the  tumor  seized  with  a  volsella  and  pulled  down, 
while  an  assistant  presses  on  the  fundus  uteri.  If  the  tumor  is  not 
very  small,  a  better  hold  of  it  is  secured  by  passing  the  noose  of  a 
linen  tape  around  it  above  the  volsella.  If  necessary,  the  tape  may  be 
pushed  up  by  means  of  a  crutch,  an  instrument  exactly  like  a  uterine 
sound  ending  in  a  little  fork  (Fig.  263).  This  loop  allows  us  to  pull 

FIG.  263. 


Tape-carrier. 


the  polypus  considerably  down,  and  its  pedicle  is  cut  off  with  a  few 
rotary  movements  of  Thomas's  spoon-saw  (Fig.  264),  a  shallow  spoon 


FIG.  264. 


Thomas's  Spoon-saw. 

with  dull  serrated  margin.1  The  pedicle  may  be  cut  near  the  tumor, 
and  it  is  safer  to  do  so.  Subsequently  the  stump  is  drawn  into  the 
substance  of  the  uterus  and  disappears. 

1  Many  instrument-makers  make  it  too  hollow  and  with  too  sharp  teeth,  which 
changes  it  from  a  safe  and  valuable  instrument  into  a  dangerous  one. 


DISEASES  OF  THE   UTERUS.  479 

If  the  polypus  is  situated  in  the  interior  of  the  yet  closed  uterus, 
the  cervix  must  first  be  dilated  with  aseptic  laminaria  (p.  154)  or 
iodoformed  cotton  balls  (p.  156).  If  it  spring  from  the  fundus,  a  pair 
of  strongly  curved  scissors  may  be  needed  for  removing  it  (Fig.  265). 

FIG.  265. 


Bozeman's  Double-curved  Scissors. 

An  intermittent  polypus  should  be  removed  during  menstruation, 
when  it  can  be  seized  in  the  vagina. 

Very  large  polypi  may  be  brought  out,  after  the  pedicle  is  severed, 
by  means  of  the  obstetric  forceps.  Wedge-shaped  pieces  may  be  cut 
out  of  the  lower  part  of  the  tumor  in  order  to  make  it  smaller,  a  pro- 
cedure called  morcellation  ;  or  a  spiral  incision  may  be  carried  around 
it,  right  into  its  substance,  while  it  is  being  pulled  down,  which  is 
called  allongement. 

As  there  often  are  other  fibroids  imbedded  in  the  uterine  wall,  which 
in  course  of  time  become  pedunculate,  the  operation  may  have  to  be 
repeated,  although  it  is  radical  in  regard  to  the  tumor  it  is  applied  to. 

Subperitoneal  tumors  can  only  be  reached  by  laparotomy  (see  Ova- 
riotomy). If  they  have  a  well-developed  pedicle,  it  should  be  trans- 
fixed, and  a  double  silk  ligature  of  proportionate  strength  drawn 
through  and  cut  into  two  halves,  which  are  made  to  cross  one  another 
so  as  to  form  two  interlocked  loops,  each  of  which  is  tied  on  opposite 
sides  (Fig.  260).  The  object  in  dealing  with  the  pedicle  in  this  way 
is  to  prevent  the  ligature  from  slipping,  which  may  cause  fatal  hem- 
orrhage. 

Great  relief  from  pressure  on  rectum,  bladder,  or  nerves,  or  from 
pulling  on  ligaments,  may  be  afforded  by  lifting  the  tumor  up,  and 
sometimes  it  may  be  prevented  from  falling  down  again  by  a  pessary, 
such  as  a  large-sized  Gehrung's  (Fig.  246,  p.  436)  or  Thomas's  (Fig. 
244,  p.  435),  or  an  abdominal  belt  with  vaginal  cup  (Fig.  253, 
p.  456). 

Medical  Treatment. — Alone  or  as  an  adjuvant  to  other  measures 
medicinal  treatment  is  of  considerable  value  in  combating  symptoms, 
and  may  even  occasionally  effect  a  radical  cure.  The  chief  symptoms 
that  call  for  medicinal  treatment  are  hemorrhage  and  leucorrhea,  and 
we  refer  to  what  has  been  said  on  this  subject  in  the  general  part 


480  DISEASES  OF  WOMEN. 

under  Hemostaties  (p.  227),  Menorrhagia  (p.  245),  and  Leucorrhea 
(p.  251).  The  writer  would  particularly  call  attention  to  the  value 
of  gossypium  for  combating  hemorrhage  and  pain.  Ergot  may  be 
given  by  the  mouth,  in  suppositories  (extr.  ergotae,  gr.  ij— v  in  each, 
one,  two,  or  three  times  a  day),  or  hypodermically.  For  the  latter 
purpose  ergotin  (gr.  ij  or  iij)  or  sclerotinic  acid  (gr.  f)  is  preferred. 

Some  years  ago,  before  the  Apostoli  treatment  was  introduced,  I 
used  such  injections  and  saw  good  effect  from  them.  The  formula  was 

U.  Acidi  sclerotinici,  gr.  x  ; 

Glycerini,  3ss; 

Aq.  dest.  q.  s.  ad  sij. 

M.  Sig.  Eight  minims  hypodermically. 

The  injections  are  made  in  the  abdominal  wall  in  front  of  the  tumor, 
and  they  should  be  very  deep.  The  syringe  must  be  clean  and  the 
skin  made  aseptic.  By  so  doing  I  have  never  seen  an  abscess  form, 
but  each  injection  is  accompanied  by  considerable  pain,  redness,  and 
swelling,  and  leaves  a  knob  slow  to  disappear.  The  injections  were 
repeated  three  times  a  week.  This  treatment  has  afforded  so  good 
results  in  the  hands  of  many  observers  besides  myself,  leading  even 
in  some  cases  to  the  total  disappearance  of  the  tumor,  that  under 
circumstances  it  is  well  worth  trying.  As  a  rule,  the  method  is  safe. 
Too  large  doses  of  ergot  have,  however,  caused  symptoms  of  pois- 
oning; and  a  case  has  been  reported  in  which  the  tumor  became 
gangrenous,  and  the  patient  died  of  septicemia.1 

Instead  of  sclerotinic  acid,  ergotin  (gr.  iij  pro  dosi)  may  be  used 
dissolved  in  five  parts  of  water : 

!$$.  Ergotini  (Squibb),  3ss; 

Aq.  dest.,  3jjss ; 

Acid,  carbol.,  TTLij. 

M.  Sig.  Eighteen  minims  for  each  injection. 

To  inject  ergot  preparations  into  the  substance  of  the  uterus  is  dan- 
gerous and  offers  no  advantage. 

Among  mineral  waters,  Kreutznach,  used  both  internally  and  in 
fomentations  and  baths,  has  the  best  reputation  for  its  effect  on 
fibroids. 

With  the  exception  of  polypi,  pedunculate  subperitoneal  fibroids 
and  fibrocysts,  most  other  fibroids  should,  if  possible,  be  treated  with 
galvano-e.hemical  cauterization  after  Apostoli's  method  (p.  233).  In 
cases  of  hemorrhage  and  leucorrhea  the  positive  pole  is  used  in  the 
uterus ;  in  more  dry  cases  the  negative.  If  the  electrode  can  be  intro- 
duced into  the  canal,  there  is  hardly  any  danger.  I  allow  even  the 
patient  to  go  home  by  street-car  and  elevated  railroads  immediately 

1  W.  T.  Lusk,  N.  Y.  Med.  Jour.,  July,  1882,  vol.  xxxvi.  p.  30. 


DISEASES  OF  THE   UTERUS.  481 

after  the  application,  which  I  prefer  to  make  in  the  office,  where  more 
perfect  apparatus  is  available.  The  first  effect  is  to  assuage  pain, 
which  gains  the  patient's  confidence.  In  the  vast  majority  of  cases 
the  tumor  will  become  smaller,  and  in  some  it  disappears.  Hemor- 
rhage will  nearly  always  cease.  The  softer  the  tumor  is — that  is  to 
say,  the  less  connective  tissue  and  the  more  serum  are  contained  in 
the  muscular  bundles — the  better  are  the  prospects.  In  some  cases 
I  have  seen  parts  of  the  tumor  gradually  pushed  out,  so  as  to 
form  prominences  in  the  peritoneal  cavity.  The  method  is  compara- 
tively safe  and  promises  so  much,  and,  on  the  other  hand,  the  cutting 
operations  are  so  dangerous,  that,  as  a  rule,  electricity  should  be  given 
a  fair  trial  before  resorting  to  the  latter.1  The  method  is,  however, 
not  devoid  of  danger.  Sometimes  local  peritonitis  may  follow  the 
application,  and  some  uteri  are  so  distorted  by  the  fibroids  they  con- 
tain that  some  places  of  the  wall  may  become  very  thin.  If  it  should 
happen  that  the  intra-uterine  electrode  were  applied  to  such  a  place, 
the  cauterization  might  go  through  the  whole  thickness  of  the  wall. 

Many  patients,  however,  cannot  get  the  tedious  galvanic  treatment, 
and,  moreover,  the  experience  of  later  years  has  shown  that  by  ope- 
rating early  the  prognosis  for  the  operation — like  that  for  ovariotomy 
— has  become  much  better. 

Hemorrhage  may  be  checked  by  curetting  (p.  176).  Perhaps,  it 
only  gives  relief  for  some  months,  but  may  then  be  repeated.  By 
thus  scraping  off  the  hypertrophied  endometrium  the  patient  may 
sometimes  be  kept  alive  until  the  menopause  arrives  and  brings  per- 
manent relief.2  Properly  performed,  the  operation  is,  as  a  rule,  harm- 
less; the  writer  has,  however,  had  a  case  in  which  it  was  followed 
by  gangrene.3 

Vaginal  Enucleation  by  Means  of  the  Spoon-saw. — Large  sessile 
myomas,  weighing  up  to  three  pounds,4  have  been  successfully  re- 
moved through  the  vagina.  The  method  is  applicable  to  both  cervical 
and  corporeal  fibroids.  The  patient  is  placed  in  Sims's  position,  and 
his  largest  speculum  is  introduced.  If  the  cervix  is  partially  open, 
and  the  tumor  offers  a  free  end  near  it,  the  cervix  is  seized  with  a 

1  Thomas  Keith,  who,  at  a  time,  was  by  far  more  successful  than  all  contempora- 
neous operators,  who  had  a  mortality  of  only  8  per  cent,  in  hysterectomy,  and  only 
lost  1  patient  in  almost  100  cases  of  oophorectomy  for  uterine  fibroma,  rejects  even 
the  minor  operation  in  favor  of  Apostoli's  method  ("  Contributions  to  the  Surgical 
Treatment  of  Tumors  of  the  abdomen,  Part  II.,"  Electricity  in  the  Treatment  of  Ute- 
rine  Tumors,  Edinburgh,  1889,  p.  viii.).   Only  when  the  galvanic  treatment  fails  does 
he  perform  hysterectomy  (Gyn.  Trans.,  1890,  vol.  xv.  p.  143). 

2  An  instructive  paper  on  this  subject  was  published  by  Henry  C.  Coe  in  The  Med- 
ical Record,  Jan.  28,  1888. 

3  The  patient  recovered,  and  was  radically  cured,  but  another  time  the  result  might 
be  less  favorable.     I  scraped  away  what  I  could  with  the  finger,  tore  dead  shreds  off 
with  forceps,  and  used  carbolized  intrauterine  and  vaginal  injections. 

4  Thomas,  Amer.  Jour.  Med.  Sc.,  April,  1880,  vol.  Ixxix.  p.  405  ;  Munde",  Amer.  Jour. 
Obst.,  1885,  vol.  xviii.  p.  189. 

31 


482  DISEASES  OF  WOMEN. 

tenaculum-forceps  and  severed  bilaterally  up  to  the  vaginal  vault.  A 
volsella  is  fixed  in  the  lower  end  of  the  growth,  and  the  uterine 
attachments  severed  with  the  spoon-saw.  The  cavity  should  next  be 
washed  out  with  disinfectant  fluid  and  packed  with  iodoform  gauze 
(p.  180). 

If  the  cervix  is  open  and  the  tumor  entirely  imbedded  in  the  wall 
of  the  body  or  situated  in  the  cervix,  a  strong  tenaculum  is  plunged 
into  it,  and  a  hole  is  cut  with  scissors  in  the  lowest  part  of  the  pre- 
senting mucous  membrane  covering  the  tumor.  This  is  extended  on 
a  director,  the  mucous  membrane  detached  with  the  finger,  a  vol- 
sella fastened  in  the  white  tissue  of  the  myoma,  and  the  spoon-saw 
introduced  and  swept  all  around,  detaching  the  tumor  from  its  uterine 
bed  for  about  an  inch  and  a  half  or  two  inches,  while  traction  is 
kept  up.  If  the  tumor  is  too  large  to  be  dragged  down  as  a  whole,  it 
is  removed  piecemeal.  For  this  purpose  pieces  large  as  hen's  eggs 
are  cut  out,  one  after  the  other,  from  the  detached  part  of  the  tumor. 
Then  the  tumor  is  again  seized  with  the  volsella,  a  new  zone  de- 
tached and  removed  piecemeal  in  the  same  way,  and  so  forth  until 
the  remainder  can  be  removed  with  the  spoon-saw  in  one  piece.  It 
is  only  the  first  incision  that  is  accompanied  by  serious  hemorrhage ; 
the  tumor  itself  has  few  vessels,  and  the  spoon-saw  with  its  blunt 
serrated  edge  peels  it  out  from  its  bed  without  much  bleeding. 

If  the  cervix  is  closed,  it  must  be  thoroughly  dilated  before  enu- 
cleation  is  begun.  For  this  purpose  it  is  split  up  to  the  vaginal 
junction  with  Kiichenmeister's  scissors,  and  the  internal  os  incised 
bilaterally  with  Simpson's  metrotome  (p.  423),  until  all  resistance  is 
overcome,  and  finally  full  dilatation  is  obtained  by  using  tents  or 
cotton  balls  impregnated  with  iodoform,  procedures  which  take  days 
and  weeks,  and  during  which  I  more  than  once  have  seen  the 
patients  succumb  to  septicemia. 

Greater  than  the  danger  from  hemorrhage  is  that  of  perforating  the 
uterus.  It  is  impossible  to  know  if  the  tumor  has  more  than  a  peri- 
toneal covering.  At  all  events,  the  spoon-saw  must  be  kept  close  up 
to  the  tumor.  In  pulling  the  uterus  down  it  may  become  inverted 
(p.  466),  and  the  inverted  part  must  be  replaced  as  soon  as  the  fibroid 
is  enucleated.  The  danger  from  septicemia  after  the  operation  is  also 
considerable.  In  fact,  the  dangers  are  so  great  that  this  method  can- 
not be  recommended  for  entirely  imbedded  tumors,  but  for  partially 
polypoid  fibroids  I  think  it  is  less  dangerous  than  oophorectomy  and 
hysterectomy,  and  unlike  them  it  preserves  the  possibility  of  impreg- 
nation. 

In  exceptional  cases,  the  fibroid  starting  from  the  posterior  surface 
of  the  uterus  presses  against  the  vagina,  and  may  be  enucleated  through 
an  incision  there. 

Emmet's  Traction  Method  is,  in  some  respects,  like  the  preceding 


DISEASES   OF  THE   UTERUS.  483 

method  of  enucleation,  but  the  capsule  is  never  opened,  and  all  is  done 
in  the  vagina,  not  in  the  interior  of  the  uterus.  The  tumor  is  seized 
with  a  volsella,  pulled  down,  and  removed  piecemeal  as  it  emerges 
from  the  os.  In  this  way  muscular  contraction  is  induced,  and  the 
surrounding  tissue  gradually  closes  upon  the  removed  tumor,  so  that 
it  becomes  pedunculate  and  leaves  only  a  small  raw  surface. 

Oophorectomy. — With  the  hope  of  bringing  about  the  menopause 
prematurely,  and  diminishing  the  size  of  the  tumor,  the  ovaries  and 
tubes  may  be  removed.  The  first  part  of  this  operation  consists  in 
laparotomy,  which  will  be  described  under  Ovariotomy.  In  regard 
to  the  next  part,  the  removal  of  the  ovaries,  the  reader  is  referred  to 
Diseases  of  the  Tubes.  If  the  tumor  is  a  large  one,  it  may  be  very 
difficult  to  reach  the  ovaries.  The  uterus  must  not  be  tilted  out 
of  the  abdominal  cavity,  as  it  may  suddenly  become  so  congested 
that  it  cannot  be  replaced.  It  may,  however,  be  advantageously 
turned  on  its  longitudinal  axis.  But  the  ovaries  may  be  so  im- 
bedded in  adhesions  and  inflammatory  masses  that  it  proves  impossi- 
ble to  remove  them.  Gangrene  of  the  myoma  has  followed  the 
removal  of  the  ovaries.  If  the  cavity  of  the  uterus  measures  over 
six  inches,  there  is  little  hope  that  the  operation  will  be  of  avail. 
On  account  of  hemorrhage  it  is  not  safe  to  tear  adhesions  which 
cannot  be  brought  into  view. 

Oophorectomy  for  fibroids  is  practised  much  less  now  than  some 
years  ago,  hysterectomy  having  become  much  less  dangerous  than  it 
was  at  that  period. 

If  it  is  impossible  to  remove  the  ovaries,  or  if  the  patient  is  so 
weak  that  she  cannot  stand  the  greater  operations,  the  menopause  may 
perhaps  yet  be  brought  about  by  tying  the  ovarian  blood-vessels,  or, 
better,  all  six  arteries  supplying  the  uterus  with  blood.1 

Hysterectomy,  or  complete  extirpation  of  the  uterv^,  may  be  per- 
formed through  the  vagina — vaginal  hysterectomy — or  through  the 
abdominal  wall — abdominal  hysterectomy — or  by  both  ways  combined 
— vagino-abdominal  hysterectomy. 

Vaginal  hysterectomy"  may  be  performed  with  pressure-.forceps,  liga- 
tures, or  without  either. 

Modus  Operandi. — Clamp  Method. — The  patient  lies  on  her  bade, 
the  legs  held  up  with  a  suitable  leg-holder  (p.  197).  The  lower  end 
of  the  table  is  raised  about  four  inches.  The  genitals  having  been 
shaved  and  disinfected,  and  the  vagina  disinfected  (p.  196),  Garrigues' 
self-retaining  weight  speculum  (Fig.  177,  p.  211)  is  introduced,  and 

1  C.  C.  Frederick  of  Buffalo  reports  good  results,  especially  enormous  shrinkage  of 
the  uterus,  by  tying  both  uterine  arteries,  either  from  the  vagina  or  after  laparotomy 
(Amer.  Jour.  Obst.,  Sept.,  1895,  vol.  xxxii.  p.  348).  Rydygier,  who  was  the  first  to  pro- 
pose this  treatment,  publishes,  however,  a  case  in  which  he  tied  all  six  arteries,  and 
yet  hemorrhage  returned  after  ten  months  (Centralbl.  f.  Gyndk.,  1894,  vol.  xviii.  p. 
297). 


484 


DISEASES  OF  WOMEN. 


depresses  the  posterior  wall  of  the  vulva  and  vagina,  or  this  is  done 
with  a  univalve  speculum  held  by  an  assistant  (Fig.  266,  6).  The 
anterior  wall  is  held  up  with  a  short,  broad,  univalve  speculum  (Fig. 
266,  a).  The  cervix  is  seized  laterally  with  a  bullet-forceps,  and  dilated. 
The  uterus  is  curetted  and  wiped  with  sterilized  gauze  wound  around 
a  pair  of  forceps.  Next,  a  four-pronged  traction-forceps  (Fig.  181,  p. 
212)  is  inserted  in  the  middle  of  the  posterior  lip  and  another  oppo- 
site to  it  in  the  anterior  lip.  With  these  the  cervix  is  moved  up  and 
•down  so  as  to  show  the  utero- vaginal  junction.  The  cervix  is  then 
drawn  forward  toward  the  symphysis,  exposing  the  posterior  cul-de- 
sac  well.  A  transverse  incision  is  made  with  a  scalpel,  at  the  utero- 
vaginal  junction,  about  an  inch  above  the  end  of  the  vaginal  portion. 

FIG.  266. 


Segond's  Speculum :  a,  anterior  blade ;  6,  posterior  blade. 

Next,  the  cervix  is  drawn  back  and  a  similar  incision  is  made  in 
front,  just  below  the  bladder,  about  half  an  inch  above  the  end  of 
the  vaginal  portion.  This  is  carried  round  the  cervix  till  it  merges 
in  the  posterior  incision,  the  two  forming  one  circular  incision  close 
up  to  the  cervix.  Next,  a  longitudinal  incision,  two-thirds  of  an 
inch  long,  is  made  on  both  sides  corresponding  to  the  transverse 
diameter  of  the  os,  and  carried  through  the  mucous  membrane  so  as 
to  unite  at  right  angles  with  the  circular  incision.  This  enables  the 
operator  to  make  a  larger  anterior  flap  and  carry  the  bladder  and 
ureters  well  out  of  the  way.  It  is  used  in  all  vaginal  hysterectomies 
in  which  the  cervix  is  small  or  the  uterus  large.  Once  the  incisions 
made,  the  operator  pulls  steadily  down  on  the  cervical  volsella3,  cut- 


DISEASES  OF  THE   UTERUS.  485 

ting  with  small  nicks  of  scissors  and  using  the  nails  of  his  thumb 
and  forefinger  as  much  as  possible.  Behind,  the  peritoneal  cavity  is 
soon  reached,  and  the  opening  is  enlarged  by  pulling  the  peritoneum 
apart  from  side  to  side  with  the  two  forefingers,  while  the  posterior 
speculum  is  temporarily  removed.  This  posterior  opening  is  large 
enough  to  admit  two  or  three  fingers.  In  front  the  operator  proceeds 
in  a  similar  way,  exposing  as  much  of  the  uterus  as  he  can  and  with- 
out paying  any  attention  to  the  peritoneum.  On  the  sides  he  can 
push  up  the  parametria  almost  without  cutting  until  he  is  near  the 
broad  ligament.  No  retractor  should  ever  be  inserted  between  the 
bladder  and  the  uterus,  as  it  draws  the  ureters  together  and  might 
wound  them  or  the  bladder.  The  retractor  should  only  be  held  flat 
against  the  mons  Veneris,  at  right  angles  to  the  uterus,  and  push  the 
bladder  up. 

So  far  no  attention  whatsoever  is  paid  to  hemostasis,  but  when  the 
operator  has  proceeded  in  front  as  far  as  he  can  and  on  the  sides  is 
nearly  through  the  parametriuni,  he  places  a  pair  of  strong  hemostatic 
forceps  (Fig.  267)  on  the  lower  part  of  the  broad  ligament,  including 

FIG.  267. 


Long  Pressure-forceps. 


the  uterine  artery.  The  forceps  is  put  on  in  a  peculiar  way.  The 
operator  holds  it  close  up  to  the  cervix,  holds  the  open  jaws  in  front 
and  behind  the  uterus  and  moves  the  point  outward,  describing  part 
of  a  circle,  by  which  he  is  sure  to  push  the  bladder  and  ureter  out  of 
the  way,  before  he  clamps  the  artery.  Next,  he  closes  the  forceps 
just  outside  the  uterus  and  cuts  with  scissors  the  tissue  close  up  to 
the  clamps  and  near  up  to  their  end,  which  makes  the  uterus  much 
more  mobile.  The  posterior  speculum  is  then  removed  for  good.  The 
anterior  wall  of  the  uterus  is  pulled  down.  As  soon  as  feasible  the 
uterus  is  anteflexed  and  the  fundus  brought  into  the  wound,  for  which 
purpose,  as  a  rule,  the  uterus  is  incised  or  pieces  cut  out  of  it,  which 
procedure  presently  will  be  described.  The  adnexa  are  pulled  out 
into  the  wound,  if  necessary  after  loosening  adhesions  with  two  fingers 
introduced  into  the  pelvis.  This  is  the  only  step  that  is  done  by  feel- 
ing alone;  otherwise  all  is  done  in  the  wound  under  the  control  of  the 


486  DISEASES  OF   WOMEN. 

eye.  When  the  appendages  of  the  left  side  are  brought  out,  a  pair 
of  hemostatic  forceps  are  placed  from  above  over  the  broad  ligament, 
outside  of  the  appendages,  and  brought  in  contact  with  the  forceps  com- 
pressing the  lower  part  of  the  same.  This  compresses  the  ovarian  vessels. 
The  uterus  is  then  cut  loose  on  this  side,  and  .the  broad  ligament  of 
the  other  side  is  clamped  and  cut  in  a  similar  way.  If  there  is  any 
bleeding  from  the  cut  surface,  another  clamp  is  placed  outside  of  the 
first  and  this  one  removed.  Thus,  in  a  typical  case,  only  four  clamps 
will  be  left  in  the  vagina,  but  if  needed  more  are  added.  When  the 
uterus  has  been  removed,  the  operator  should  look  carefully  for  any 
bleeding.  For  this  purpose  a  pair  of  Plan's  long  narrow  retractors 
are  introduced,  one  in  front  aud  one  behind,  by  means  of  which  a 
view  is  obtained  deep  into  the  abdominal  cavity,  so  that  even  the 
appendix  vermiformis  of  the  caecum  may  become  visible.  These 
retractors  are  much  like  Schroeder's  (Fig.  178,  p.  212),  but  longer 
and  broader,  the  blade  measuring  five  by  one  and  a  quarter  inches. 
In  searching  for  bleeding  points,  real  sponges  as  large  as  hens'  eggs, 
on  account  of  their  great  porosity,  are  preferable  to  gauze  pads. 

When  all  bleeding  points  have  been  secured,  the  wound  is  tamponed 
with  long  strips  of  dry  sterilized  gauze.  Each  strip  is  a  quarter  of  a 
yard  wide  and  several  yards  long.  It  is  folded  in  several  layers 
lengthwise,  so  as  to  be  about  two  inches  wide,  and  this  pad  is  again 
folded  transversely  in  zigzag  at  the  top,  and  carried  in  just  beyond 
the  jaws  of  the  clamps.  If  there  is  any  suppuration,  iodoform  gauze  is 
used  instead  of  sterilized  gauze.  The  vagina  is  packed  loosely  out- 
side of  the  handles  of  the  clamps  with  iodoform  gauze.  For  safety's 
sake  the  rings  of  each  forceps  may  be  tied  together  separately.  The 
handles  are  surrounded  with  absorbent  cotton  held  together  with  a 
string.  A  self-retaining  soft-rubber  catheter  (Fig.  268)  is  left  in  the 


FIG.  268. 


Petzer's  Self-retaining  Soft-rubber  Catheter :  a,  bulb ;  6,  flange. 

bladder  and  closed  with  a  small  pressure- forceps.  It  is  introduced 
by  entering  a  uterine  sound  through  the  central  opening  of  the  bulb 
A,  and  pressing  it  up  against  a  point  in  the  periphery.  The  bladder 
is  emptied  every  two  hours. 

The  clamps  as  well  as  the  surrounding  dressing  are  removed  forty- 
eight  hours  after  the  operation.  If  there  is  no  fever,  the  pelvic  tam- 
pon is  left  in  for  six  or  eight  days.  It  becomes  very  offensive,  but 
is  removed  more  easily  than  at  an  earlier  date.  If  the  patient  be- 
comes feverish,  the  packing  is  removed  at  once. 


DISEASES  OF  THE   UTERUS. 


487 


If  the  omeutum  sinks  down,  cither  during  the  operation  or  after 
removal  of  the  tampon,  it  must  be  pushed  high  up  with  a  sponge  or 
pad  on  a  holder  so  as  to  prevent  its  agglutination  to  the  wound. 

If  the  intestine  is  adherent,  a  reasonable  amount  of  adhesive  tissue 
should  be  left  on  it  to  go  off  by  suppuration. 

The  tampons  are  removed  gradually  by  pulling  down  and  cutting 
off  a  piece  every  day.1 

Ligature  Method. — If  we  want  to  use  ligatures,  the  two  transverse 
incisions  in  the  vagina  are  not  united,  but  a  bridge,  half  an  inch  wide 
and  two-thirds  of  an  inch  long,  is  left  on  each  side  of  the  cervix. 
The  posterior  cul-de-sac  is  opened  as  described  above.  As  soon  as 
the  peritoneum  of  the  utero-vesical  pouch  is  reached,  it  is  incised  and 
torn  from  side  to  side,  so  that  we  have  one  opening  behind  and  one 
in  front  of  the  uterus. 

The  parametrium  on  the  left  side  is  surrounded  with  a  strong  liga- 
ture carried  with  a  half-blunt,  handled  needle,  bent  to  the  side  (Fig. 
269),  or  with  Folk's  hinged  needle  (Fig.  270),  a  curved,  blunt  needle, 

FIG.  269. 


Schroeder's  Needle. 


with  the  eye  near  the  point  and  a  movable  joint  which  is  fixed  by  a 
button  on  the  side.2    After  having  cut  the  tissue  between  the  ligature 


FIG.  270. 


Folk's  Needle :  A,  movable  needle ;  B,  B,  the  needle  brought  backward  and  forward ;  C, 
button  for  stopping  movement. 

and  the  uterus,  another  ligature  is  carried  over  the  tissue  situated 
above  that  comprised  in  the  first  ligature.  Next,  similar  ligatures  are 
placed  on  the  right  parametrium,  which  is  also  cut.  Then  we  return 

1  The  operation  here  described  is  in  all  essentials  that  of  Dr.  Paul  Segond  of 
Paris,  an  adherent  of  Pean. 

2  W.  M.  Polk,  Amer.  Jour.  Obst.,  1887,  vol.  xx.  p.  294. 


488  DISEASES  OF  WOMEN. 

to  the  left  side,  tying  and  cutting  until  the  whole  broad  ligament  has 
been  tied  in  small  portions,  which,  when  tightened,  ought  not  to  exceed 
the  thickness  of  a  lead  pencil.  The  application  of  the  upper  liga- 
tures is  very  much  facilitated  by  throwing  a  strong  silk  thread  over 
the  ligament  by  means  of  J.  B.  Hunter's  needle,  which  is  constructed 
on  the  principles  of  Bellocq's  tube  for  plugging  the  posterior  nares. 
If  possible,  the  tube  and  ovary  should  be  drawn  inside  of  the  upper- 
most ligature,  or  they  may  be  tied  separately  and  removed. 

When  the  left  side  of  the  uterus  is  free,  the  right  broad  ligament 
with  the  appendages  becomes  much  more  easy  to  handle,  and  is  se- 
cured with  a  few  ligatures  passed  from  above  downward. 

In  regard  to  the  material  to  be  used  for  the  ligatures  tastes  diifer. 
If  silk  is  used,  the  threads  should  be  left  long,  and  pulled  out  when 
they  become  loose.  If  catgut  is  used,  which  is  just  as  well  in  other 
respects,  it  is  cut  short,  and  is  expelled  together  with  the  tissue  form- 
ing the  button  of  the  ligature  during  the  healing  process. 

If  there  is  hemorrhage  from  the  cut  surface  of  the  parametrium 
behind  or  in  front  of  the  cervix,  it  may  be  checked  by  uniting  the 
edge  of  the  peritoneum  with  that  of  the  mucous  membrane  of  the 
vagina.  If  there  is  still  any  bleeding  from  the  depth,  it  may  be 
checked  by  means  of  a  Mikulicz  tampon  (p.  181).  Otherwise  the 
opening  at  the  top  of  the  vagina  and  the  vagina  itself  are  only  packed 
loosely  with  iodoform  gauze. 

Some  go  a  step  farther  and  close  the  whole  wound,  drawing  the 
stumps  of  the  broad  ligaments  into  the  vagina.  This  makes  recovery 
speedier,  avoids  the  disagreeable  odor  of  decaying  tissue,  and  prevents 
prolapse  of  the  vagina,  but  makes  the  operation  more  difficult  and 
tedious. 

Comparison  between  Ligatures  and  Forceps. — Whether  a  surgeon 
will  prefer  ligatures  or  forceps  depends  often  more  on  personal  predi- 
lection and  aptitude  than  on  anything  else.  Forceps  may  be  applied 
at  a  depth  where  ligatures  cannot  be  applied  and  where  there  is  not 
tissue  enough  to  form  a  button.  The  application  takes  less  time,  and 
is  perfectly  safe  unless  impatient  and  reckless  operators  remove  the 
forceps  too  soon.  If,  however,  a  serious  hemorrhage  occurs  after  the 
vagina  is  partially  filled  with  forceps,  it  may  be  very  difficult  to  check 
it.  The  removal  of  forceps  and  of  the  pelvic  packing  is  very  pain- 
ful. Great  care  must  be  taken  to  avoid  pressure-necrosis  of  the  vulva 
from  forceps.  In  certain  operations,  such  as  those  for  large  fibroids 
and  for  extensive  pelvic  inflammation,  forceps  alone  are  available. 
Often  it  is  an  advantage  to  combine  both  methods,  and  not  to  bind 
one's  self  stubbornly  to  either  of  them.  Especially,  it  is  sometimes 
an  advantage  to  use  ligatures  for  the  easily  accessible  parametria, 
which  leaves  more  room  for  the  following  manipulations  of  the  uterus 
and  ligaments.  It  has  been  contended  that  unless  the  vaginal  wall 


DISEASES  OF  THE   UTERUS. 


489 


is  stitched  to  the  broad  ligaments,  and  unless  the  vagina  is  brought 
well  up  toward  the  peritoneum,  prolapsus  of  the  vagina  invariably 
follows.1  This  is  not  borne  out  by  the  writer's  experience,  nor  does 
it  seeni  possible  that  such  an  event  can  be  of  frequent  occurrence 
without  having  been  noticed  by  those  who  have  reported  hundreds 
of  cases. 

Morcellation. — If  the  uterus  is  too  large  to  be  removed  in  one  piece, 
at  least  with  preservation  of  its  shape,  recourse  may  be  had  to  morcel- 
lation.  In  its  simplest  form  this  operation  consists  in  an  incision  in 
the  median  line  through  the  whole  thickness  of  the  anterior  wall, 
extending  more  or  less  to  the  fundus,  whereby  the  organ  becomes 
already  much  more  mobile.  Another  way  is  to  excise  a  wedge-shaped 

FIG.  271. 


Morcellation  of  Fibroid  Tumors  of  Large  Size  (Pean). 

piece  of  the  anterior  wall  or  to  make  two  incisions,  diverging  from 
below  upward,  and  remove  the  intermediate  tissue  piecemeal.  Often 
it  is  an  advantage  to  begin  by  removing  the  cervix.  In  cases  of 

1  Joseph  Eastman.  Indianapolis,  Ind.,  Amer.  Jour.  Obst.,  Feb.,  1895,  vol.  xxxi.  p. 
214. 


490  DISEASES  OF  WOMEN. 

retroflexion  the  posterior  wall  is  attacked  in  similar  ways  instead  of 
the  anterior.  Some  divide  the  uterus  into  an  anterior  and  posterior 
flap,  which  are  amputated  and  thus  give  better  access  to  the  fundus. 
Others  divide  the  whole  uterus  into  two  halves  in  the  median  line,  cut- 
ting first  the  anterior  \yall,  then,  after  having  anteflexed  the  uterus, 
the  fundus,  and,  finally,  the  posterior  wall.  Tumors  may  also  be  cut 
out  from  the  inside  of  the  uterus  with  long  straight  or  curved  knives 
and  scissors,  and  pulled  out  with  forceps  with  teeth  like  N6laton's 
cyst-forceps  (see  Ovariotomy  and  Fig.  271). 

In  all  these  operations  the  uterine  arteries  are  first  secured,  and,  if 
possible,  the  broad  ligaments  too,  but  often  this  is  impossible,  and 
hemostasis  is  then  obtained  provisionally  by  pulling  the  uterus  down 
all  the  time,  and  often  by  everting  the  fuudus  and  thus  twisting  the 
broad  ligaments ;  besides  that  the  uterine  tissue  itself  does  not  bleed 
much. 

Before  cutting  off  any  piece  of  the  uterus  a  good  hold  on  the 
remainder  must  be  secured  with  a  bullet-forceps  or  a  four-pronged 
(Fig.  181,  p.  212)  or  eight-pronged  traction-forceps.  Another  prin- 
ciple is  only  to  cut  what  can  be  seen,  and  to  see  or  feel  all  tissue  that 
is  being  ligated  or  clamped,  so  as  to  be  sure  of  not  including  the 
intestine  in  the  part  grasped.  With  large  tumors  the  principle  is  to 
remove  as  much  as  poasible  of  the  tumors,  and'  deal  with  the  uterus 
subsequently.  In  all  cases  the  uterine  cavity  should  be  disinfected. 
While  a  moderate  morcellation  is  easy  to  perform  and  very  helpful, 
it  need  hardly  be  said  that  the  last  described  procedures  are  dangerous 
and  require  great  dexterity.1 

Limits  of  Vaginal  Hysterectomy. — P6an  removes  all  uterine  fibroids 
by  the  vaginal  method,  if  the  fundus  is  below  or  even  a  little  above 
the  umbilicus.  In  most  operators'  hands  it  will  probably  be  safer  to 
prefer  the  abdominal  section  when  the  uterus  is  larger  than  a  normal 
fetal  head  at  the  end  of  gestation. 

Vaginal  Hysterectomy  without  Ligature  or  Pressure-forceps. — The 
uterus  and  the  appendages  may  be  removed  without  securing  a  single 
vessel.  This  is  based  on  the  anatomical  fact  that  the  trunks  of  the 
large  arteries,  the  uterine  and  the  ovarian,  are  situated  in  the  broad 
ligaments  at  some  distance  from  the  uterus,  tubes,  and  ovaries,  and 
only  send  small  branches  into  these  organs.  In  regard  to  the  uterus 
the  writer  has  found  and  showed  in  medical  societies  that  each  branch 
of  the  uterine  artery  has  a  very  fine  bore  and  a  very  thick  muscular 
coat,  so  that  the  very  severance  of  the  little  vessels  makes  its  thick 
muscular  wall  contract.  If,  however,  a  few  arteries  spurt,  they  are 
seized  separately  and  tied.  The  advantage  claimed  for  this  method 
is  that  we  avoid  compressing  nerves,  which  we  do  in  using  ligatures 

1  Details  about  morcellation  may  be  found  in  an  article  by  Edgar  Garceau,  in 
Amer.  Jour.  Obst.,  March,  1895,  vol.  xxxi.  pp.  305-346. 


DISEASES  OF  THE   UTERUS.  491 

or  forceps.  The  operation  is  feasible,  but  less  safe  than  the  other 
methods.1 

The  writer  has  successfully  removed  the  uterus  in  this  way  in  cases 
in  which  the  appendages  had  been  removed  before,  but  a  case  ending 
fatally  from  hemorrhage  has  been  mentioned  in  a  society  meeting  in 
this  city. 

The  opening  left  at  the  top  of  the  vagina  by  hysterectomy  closes 
by  granulation  in  the  course  of  three  weeks.  The  patient  may  be 
allowed  to  get  up  at  the  end  of  the  second  week.  As  soon  as  the 
wound  canal  is  shut  off  from  the  abdominal  cavity  by  granulation, 
vaginal  antiseptic  injections  may  be  used.  There  is  often  formed 
some  wild  flesh  which  does  not  heal,  and  may  keep  up  a  discharge 
indefinitely.  These  granulations  ought  to  be  scraped  off  with  a  sharp 
curette  and  the  wound  touched  with  lunar  caustic. 

Vagino-abdominal  Hysterectomy. — Modus  Operandi. — 1 .  JBarden- 
heuer's  Method? — A  circular  incision  is  made  around  the  cervical  por- 
tion, and  the  vaginal  wall  separated  from  the  cervix.  A  tampon  of 
iodoform  gauze  is  left  in  the  vagina.  Next,  laparotomy  is  performed 
with  the  patient  in  Trendelenburg's  position  (p.  138).  The  incision 
will  extend  from  the  symphysis  pubis  to  the  umbilicus  or  still  farther. 
In  so  doing  most  operators  go  to  the  left  of  the  umbilicus,  but  Keith 
used  to  go  right  through  it.  A  corkscrew  is  bored  into  the  uterus,  by 
which  it  is  more  easily  tilted  out  through  the  wound  and  manipulated 
later.  If  the  tumor  is  not  very  large,  the  fundus  may  be  seized  with  a 
strong  volsella  instead  of  using  a  corkscrew.  After  turning  out  the 
uterus  the  edges  of  the  abdominal  incision  above  it  are  held  together 
and  covered  with  a  flat  sponge  or  pad.  With  large  tumors  extending 
far  beyond  the  umbilicus  the  writer  has  found  it  advantageous  to  in- 
sert four  sutures  through  the  whole  thickness  of  the  abdominal  wall 
before  turning  out  the  uterus,  and  tie  them  after  it  is  done  and  before 
commencing  the  removal  of  the  uterus.  The  infundibulo-pelvic  liga- 
ment, including  the  ovarian  arteries,  is  tied,  a  long  pressure-forceps 
(Fig.  267)  placed1  inside  of  the  ligature,  nearer  the  uterus,  and  the 
intervening  tissue  cut.  Then  the  remaining  part  of  the  broad  liga- 
ments is  tied  in  one  portion,  and  cut  loose,  the  ligatures  bein^r  passed 
with  Schroeder's  (Fig.  269)  or  Folk's  needle  (Fig.  270).  Next,  a 
transverse  incision  is  made  a  finger-breadth  above  the  bottom  of  the 
vesico-uterine  pouch  and  the  bladder  separated  from  the  cervix.  A 
similar  incision  behind,  in  Douglas's  pouch,  separates  the  rectum  from 

1  It  is  an  old  operation,  having  been  performed  as  early  as  1822,  revived  in  our 
days  by  Dr.  E.  H.  Pratt  of  Chicago. — Jour.  Orificial  Surg.,  June,  1894;  Geo.  Engel- 
mann,  "History  of  Vaginal  Hysterectomy,"  Amer.  Jour.  Obst.,  Feb.,  1895,  vol.  xxxi. 
p.  295. 

2  I  call  it  so  for  brevity's  sake.     The  chief  features  are  Bardenheuer's,  and  de- 
scribed with  histories  of  cases  as  early  as  1881  in  his  work  Die  Drainirung  <ler  Peri- 
t&nealhohle,  but  minor  improvements  by  others  are  included  in  the  description. 


492  DISEASES  OF  WOMEN. 

the  uterus,  which  now  hangs  only  by  a  band  on  either  side  of  the  cervix, 
containing  the  uterine  arteries.  Finally,  these  bands  are  tied  and  cut. 

On  the  side  first  cut  the  incision  should  be  made  between  two  liga- 
tures on  account  of  the  anastomosis  with  the  other  side.  On  the  other 
side  only  one  ligature  is  needed. 

If  the  tissue  containing  the  uterine  arteries  can  be  reached  and  tied 
before  opening  the  pouches  in  front  of  and  behind  the  uterus,  the 
uterus  may  be  cut  off  at  the  level  of  the  internal  os,  which  sometimes 
facilitates  the  removal  of  the  cervix. 

A  piece  of  iodoform  gauze  left  in  the  opening  serves  to  prevent 
prolapse  of  the  intestines  and  provides  for  free  drainage.  The  last 
act  of  the  operation  is  to  close  the  abdominal  wound  and  dress  it  in 
the  usual  way  (see  Ovariotomy).  A  similar  antiseptic  pad  is  laid 
over  the  vulva  and  anus,  and  fastened  with  safety-pins  to  the  bandage 
surrounding  the  body. 

After-treatment. — The  abdominal  dressing  is  left  undisturbed  for  a 
week,  and  later  changed  as  after  all  other  laparotomies.  The  gauze 
tampon  in  the  vagina  is  changed  after  two  days,  and  a  new  one  put 
in  once  a  day.  After  the  first  four  days  the  vagina  is  washed  out,  at 
the  time  of  dressing,  with  antiseptic  fluid.  The  wound  in  the  vagina 
closes  in  the  third  week  after  the  operation. 

2.  Jacobs'  method  is  also  a  vagino-abdominal  method,  but  is  ex- 
clusively performed  with  pressure-forceps.  It  is  only  used  for  large 
tumors.  Jacobs  uses  a  posterior  weight-speculum  and  two  lateral 
retractors.  The  transverse  incisions  behind  and  in  front  of  the  cervix 
are  made  with  a  curved  thermo-cautery,  leaving  a  bridge  of  mucous 
membrane,  half  an  inch  wide,  on  either  side  between  the  two  incisions. 
When  the  posterior  and  anterior  culs-de-sac  have  been  opened  into  the 
abdominal  cavity  and  stretched  from  side  to  side  with  the  forefingers, 
a  pressure-forceps  is  placed  on  each  lateral  parametrium  and  the  tissue 
cut  between  the  forceps  and  the  cervix.  The  vagina  is  then  packed 
loosely  with  iodoform  gauze,  and  the  patient  placed  in  a  level  dorsal 
position  with  the  head  turned  to  the  light.  Having  opened  the  abdo- 
men in  the  median  line  and  turned  out  the  uterus,  the  operator  places 
a  hemostatic  forceps  just  outside  of  the  left  appendage,  slanting  it 
down  toward  the  cervix,  and  another  inside  of  the  appendage,  close 
up  to  the  uterus,  and  cuts  on  the  inside  of  the  outer  forceps.  Next, 
he  places  another  hemostatic  forceps  on  the  lower  part  of  the  broad 
ligament,  securing  all  tissue  between  the  forceps  above  and  the  one 
in  the  vagina,  and  another  close  up  to  the  uterus,  and  cuts  inside  of 
the  outer.  The  same  is  repeated  on  the  right  side.  Having  removed 
the  uterus,  he  places  from  the  vagina  hemostatic  forceps  just 'outside 
of  the  four  placed  through  the  abdominal  wall,  which  he  takes  off,  and 
cuts  away  the  tissue  grasped  by  them,  so  as  to  come  close  up  to  the 
forceps  introduced  from  the  vagina.  Then  the  abdomen  is  closed,  the 


DISEASES  OF  THE   UTERUS.  493 

patient  again  turned  with  the  vagina  toward  the  light,  and  her  knees 
bent.  A  long  strip  of  sterilized  gauze,  two  and  a  half  inches  wide 
and  three  yards  long,  boiled  for  five  minutes  in  glycerin,  is  packed 
into  the  pelvis  above  all  the  forceps.  The  vagina  is  packed  loosely 
all  around  the  instruments  with  iodoform  gauze,  and  the  handles  are 
surrounded  by  a  mass  of  absorbent  cotton,  and  the  self-holding  cath- 
eter introduced  as  described  above.  The  clamps  and  vaginal  dressing 
are  removed  on  the  third  day,  the  pelvic  tampon  on  the  fourth.  This 
latter  is  not  renewed,  while  the  vagina  is  packed  loosely  every  day. 
The  bowels  are  moved  on  the  fourth  day. 

Abdominal  Hysterectomy. — Martin's  Method. — The  whole  uterus 
with  the  cervix  is  removed  through  the  abdominal  incision.  The 
peritoneum  is  stitched  to  the  vagina.  The  stumps  of  the  broad  liga- 
ments are  turned  into  the  vagina  by  means  of  the  ligatures,  which  are 
left  long,  and  finally  the  peritoneum  is  brought  together  with  another 
continuous  suture  above  the  first,  so  that  the  pelvic  cavity  is  closed 
and  covered  all  over  with  peritoneum. 

Comparison  between  the  Vaginal  and  the  Abdominal  Section. — When 
the  vaginal  method  is  feasible,  it  should  be  preferred.  Many  patients 
hate  to  have  a  large  cicatrix  on  their  abdomen  on  account  of  its  un- 
sightliness ;  in  which  respect,  however,  the  operator  can  do  much  by 
skill  and  patience  in  uniting  the  wound  after  laparotomy.  If  we  use 
tier-sutures,  most  of  them  can  be  placed  subcutaneously.  Only  thin 
silk  or  silkworm-gut  sutures  are  then  required  on  the  skin.  They 
nee.d  not  go  far  out  to  the  sides  from  the  edges  of  the  incision.  If 
aseptic  when  inserted  and  removed  in  time,  they  will  not  cause  sup- 
puration. Finally,  the  cutaneous  sutures  may  be  avoided  altogether 
by  uniting  the  edges  by  the  subcuticular  suture. 

This  method,  invented  by  Henry  O.  Marcy  of  Boston,  consists  in 
carrying  the  suture  only  through  subcutaneous  tissue  and  the  edge  of 
the  skin  without  perforating  the  epidermis.  An  absorbable  suture — 
catgut  or  kangaroo  tendon — is  introduced  through  the  skin  a  quarter 

FIG.  272. 


Subcuticular  Suture  (Marcy). 

of  an  inch  from  the  end  of  the  incision,  carried  in  the  subcutaneous 
tissue  close  up  to  the  skin,  in  a  direction  parallel  to  the  edge  of  the 
wound  for  about  half  an  inch,  then  brought  out  at  the  edge  of  the  skin 
and  inserted  in  the  other  edge  right  opposite  to  the  point  of  exit.  Here 
it  is  carried  subcutaneously  in  a  similar  way,  crossing  from  side  to  side, 
at  right  angles,  and  finally  brought  out  through  the  skin  a  quarter  of 


494  DISEASES  OF  WOMEN. 

an  inch  from  the  end  of  the  wound  (Fig.  272).  By  pulling  on  the 
two  ends  the  edges  of  the  wound  are  brought  into  contact.  Next,  the 
wound  is  dusted  with  iodoform,  and  covered  with  a  layer  of  iodoform 
collodion,  in  which  the  ends  of  the  suture  are  fastened.  The  collo- 
dion is  strengthened  by  a  few  fibers  of  absorbent  cotton,  and  the  whole 
covered  with  a  soft  cotton  pad.1  The  same  stitch  may  be  used  with 
a  silkworm-gut  suture,  the  ends  of  which  are  tied  together  over  a  pad 
of  iodoform  gauze  covering  the  wound,  and  which  is  removed  when 
the  wound  is  healed. 

Halsted  unites  the  edges  with  interrupted  sutures  of  very  fine  silk. 
These  sutures  do  not  perforate  the  epidermis,  and  when  tied  they  be- 
come buried.  They  are  taken  from  the  under  side  of  the  skin  and 
made  to  include  only  the  deeper  layers,  those  which  are  not  occupied 
by  sebaceous  follicles.  The  idea  is  to  avoid  the  pyogenic  organisms 
present  on  the  surface  of  the  skin  and  in  the  follicles.2 

Another  and  more  serious  objection  to  the  cicatrice  is  that  it  may 
yield  in  the  course  of  time  and  give  rise  to  a  ventral  hernia.  This 
danger  is  much  smaller  in  the  vaginal  section  on  account  of  the  small- 
ness  of  the  wound  and  the  thickness  of  the  cicatricial  plug  in  case  it 
is  allowed  to  heal  by  granulation.  There  is  much  less  shock  in  the 
vaginal  operation,  which  is  chiefly  due  to  the  fact  that  the  intestine  is 
not  handled.  The  patient  need  not  stay  so  long  in  bed  as  after  lap- 
arotorny,  and  the  after-treatment  is  simpler. 

On  the  other  hand,  the  vaginal  method  is  more  difficult  on 
account  of  the  smaller  dimensions  of  the  field.  Adhesions  are 
more  difficult  to  separate  or  cannot  be  reached  at  all.  Hemorrhage 
is  more  difficult  to  check.  The  bladder  and  the  intestine  are  more 
exposed  to  injury,  and  if  such  an  accident  occurs,  it  is  more  dif- 
ficult or  impossible  to  repair  the  injury.  The  pelvis  cannot  be  ex- 
plored so  easily  for  concomitant  disease,  and  the  abdomen  not  at  all. 
There  is  usually  somewhat  higher  temperature  the  first  few  days  after 
the  vaginal  operation,  and  in  most  of  the  methods  there  is  more  or  less 
dead  tissue  to  be  thrown  oif,  during  which  time  it  gives  rise  to  an 
offensive  smell. 

Special  Difficulties. — The  bladder  may  be  spread  out  and  adhere  to  the 
front  of  the  tumor.  This  condition  may  sometimes  be  diagnosticated 
before  the  operation  by  means  of  a  male  urethral  sound.  If  so,  the  in- 
cision through  the  abdominal  wall  should  be  made  above  the  upper 
limit  of  the  bladder,  the  contour  of  the  organ  made  out  by  the  sound,  an 
incision  made  corresponding  to  it,  and  the  bladder  dissected  off  from 
the  tumor,  using  as  much  as  possible  blunt  instruments  and  the  fingers. 

1  Henry  O.  Marcy  of  Boston,  "The  Surgical  Treatment  of  Inguinal  Hernia," 
Trans.  N.  Y.  State  Med.  Association,  vol.  xi.,  1894,  reprint,  p.  12;  "The  Animal  Su- 
ture," Trans.  Amer.  Assoc.  of  Obstetricians  and  Gynecologists,  1889,  reprint,  p.  24. 

2  Wm.  S.  Halsted,  Johns  Hopkins  Hospital  Bulletin,  1889,  vol.  i.  p.  13. 


DISEASES  OF  THE   UTERUS.  495 

In  order  to  avoid  wounding  the  bladder,  it  is  advisable  not  to 
empty  it  entirely  before  the  operation,  but  even  to  inject  water  into  it. 

If  the  bladder  has  been  wounded,  it  may  be  disposed  of  in  two 
ways :  either  the  wound  is  closed  separately  with  a  catgut  tier-suture 
(p.  221),  or  in  closing  the  abdominal  wall  the  whole  wall  of  the  blad- 
der is  included  in  the  stitches.  In  the  first  case,  the  mucous  mem- 
brane is  first  closed  by  one  row  of  sutures,  and  the  remaining  tissue  is 
brought  together  by  one  or  two  rows.  For  the  peritoneum  it  is  well 
to  use  Lembert's  intestinal  suture. 

If  in  the  second  case  a  urinary  fistula  forms,  it  closes  spontane- 
ously. A  permanent  catheter  should  be  left  in  the  bladder  or  the 
urine  drawn  frequently. 

If  there  is  a  persistent  urachus,  it  may  be  avoided  by  making  the 
incision  through  the  abdominal  wall  at  the  side  of  it.  If  it  has  been 
wounded,  the  wound  may  be  closed  by  comprising  it  in  one  of  the 
abdominal  sutures. 

On  the  side  of  the  cervix  great  care  must  be  taken  not  to  comprise 
the  ureter  in  a  ligature. 

The  omentum  is  often  attached  to  the  tumor.  If  the  adhesion  is 
slight,  the  separation  is  best  made  by  brushing  the  omentum  away 
from  the  tumor  with  a  sponge  squeezed  dry.  If  it  is  tough,  it  must 
be  cut  between  one  or  more  sets  of  double  ligatures. 

Sometimes  the  intestine  is  found  intimately  adherent  to  the  tumor. 
If  it  cannot  be  peeled  off",  an  incision  is  made  on  the  tumor,  through 
the  peritoneum  around  the  adhesion,  and  the  peritoneum  dissected 
off  from  the  tumor  and  left  in  connection  with  the  intestine.  Next, 

FIG.  273. 


Method  of  Closing  Peritoneal  Flap  left  on  intestine,  after  separating  it  from  uterine  fibroid 
(Schroeder) :  I,  intestine ;  P,  peritoneal  coat  of  fibroid ;  S,  catgut  suture. 

the  raw  surface  is  folded  together  by  means  of  one  or  more  catgut 
sutures  (Fig.  273). 

In  order  to  overcome  the  difficulties  presented  by  the  mere  weight 


496  DISEASES  OF   WOMEN. 

of  large  solid  abdominal  tumors  of  any  kind,  and  by  the  assistant  who 
lifts  it  being  in  the  way  of  the  operator,  Reverdin  has  invented  a 
particular  lifting  apparatus.  A  pulley  is  fastened  to  a  beam  in  the 
ceiling  of  the  operating-room  above  the  table.  Over  it  moves  a  thick 
cord,  to  the  lower  end  of  which  is  attached  a  metal  chain  dividing 
into  two  smaller  chains,  each  ending  in  a  hook.  These  hooks  are 
inserted  into  the  rings  of  a  strong  volsella,  with  which  the  tumor  is 
seized.  An  assistant,  standing  at  a  distance,  out  of  the  way  of  the 
operator,  raises  the  tumor  on  command  by  pulling  on  the  cord.  To 
the  chain  is  fastened  a  ring  or  hook,  through  which  the  free  end  of 
the  cord  is  drawn,  so  that  the  assistant  is  enabled  also  to  pull  the 
tumor  to  the  side. 

Supravaginal  Amputation  of  the  Uterus. — In  this  operation  the 
cervix  or  a  small  part  of  it  is  left  and  forms  a  stump.  There  are  two 
chief  varieties,  with  intra-abdominal  and  with  extra-abdominal  treat- 
ment of  the  pedicle. 

1.  Intra-abdominal,  Retro-peritoneal  Treatment  of  the  Pedicle. — 
The  unquestioned  victory  won  in  ovariotomy  by  the  intra-peritoneal 
treatment  over  its  rival  constantly  has  impelled  surgeons  to  apply  the 
same  principle  to  the  amputation  of  the  uterus ;  but  special  difficulties 
are  met  with  in  the  contractility  of  the  pedicle  and  the  danger  of  in- 
fection taking  place  through  the  cervical  canal — unfavorable  circum- 
stances which,  however,  to  a  great  extent,  have  been  obviated  in  dif- 
ferent ways. 

Modus  Operandi. — A  silk  ligature  is  carried  round  the  infundibulo- 
pelvic  ligament  on  one  side  and  tied,  thereby  securing  the  ovarian  ves- 
sels. In  order  to  prevent  slipping,  the  ligature  is  passed  a  little  below 
the  free  edge  of  the  ligament.  One  of  the  ends  of  this  ligature  is 
then  carried  through  the  lower  part  of  the  broad  ligament,  near  the 
uterus  and  just  above  the  uterine  artery.  When  this  has  been  tied  a 
third  ligature  is  applied  to  the  upper  part  of  the  broad  ligament,  in- 
side of  the  appendage,  which  prevent  bleeding  from  the  anastomosis 
between  the  ovarian  and  uterine  arteries. 

Next,  the  broad  ligament  is  cut  down  to  the  level  of  the  lowest 
point  of  transfixion. 

The  same  is  done  on  the  other  side. 

Then  a  superficial  incision  is  made  through  the  peritoneum,  unit- 
ing the  lower  ends  of  the  two  previous  incisions  of  the  broad  ligament 
in  front  and  behind.  It  is  made  about  a  finger-breadth  above  the 
bottom  of  the  vesico-uterine  pouch,  and  is  carried  in  a  curved  line, 
the  convexity  of  which  points  upward,  over  the  anterior  surface  of 
the  uterus.  The  lower  edge  is  seized  with  a  tissue-forcepsj  and  an 
anterior  peritoneal  flap  containing  the  bladder  and  the  ureters  is  sepa- 
rated from  the  uterus  by  means  of  the  handle  of  the  scalpel.  A  sim- 
ilar flap  having  been  dissected  off  from  the  posterior  surface  of  the 


DISEASES  OF  THE   UTERUS.  497 

Uterus,  one  end  of  the  ligature  on  the  broad  ligament  is  carried  under 
the  uterine  artery,  tied  and  cut  short.  The  same  is  repeated  on  the 
other  side.  Then  the  uterus  is  cut  away  on  a  level  with  the  internal 
os,  and  the  cervical  canal  is  touched  with  undiluted  carbolic  acid. 
Finally,  the  peritoneal  flaps  are  united  over  the  cervical  stump  by  a 
running  suture  of  catgut,  which  also  covers  the  raw  surface  of  the 
broad  ligament.  The  advantage  of  using  a  single  ligature  on  the 
broad  ligament  is  that  it  puckers  up  the  end  of  the  ligament  and  carries 
it  down  alongside  of  the  cervix,  so  that  the  raw  surface  is  very  easily 
covered  by  the  peritoneal  flaps.1 

If  the  fibrous  tissue  extends  into  the  cervix,  this  may  be  elongated 
by  constant  traction  made  upon  the  pedicle  by  the  assistant  who  is 
holding  the  tumor,  so  that  the  uterus  may  be  amputated  at  a  lower 
level,  leaving  a  cupped  surface.  Separate  fibrous  nodules  may  be 
enucleated  from  the  stump. 

2.  Extra-abdominal  Treatment  of  the  Pedicle  (Hegar's  Method). — 
When  the  uterus  is  turned  out,  an  elastic  ligature  is  thrown  around 
the  cervix,  including  the  broad  ligaments.  Only  in  exceptional  cases, 
if  the  tension  is  too  great  or  the  mass  too  voluminous,  are  the  liga- 
ments tied  first  and  cut  between  two  rows  of  ligatures.  An  elastic 
ligature — a  piece  of  rubber  tubing  as  thick  as  the  little  finger,  or  a 
solid  rubber  string  three-sixteenths  or  a  quarter  of  an  inch  thick — is 
turned  twice  around  the  cervix,  drawn  very  tight,  and  crossed  once. 
Then  the  ends  are  seized  in  front  of  the  crossing  between  the  blades 
of  a  pressure-forceps,  and  tied  together  with  a  silk  ligature  behind  the 
forceps.  When  this  is  tied,  the  ends  of  the  elastic  ligatures  are  pulled 
out  a  little  more,  and  a  second  silk  ligature  is  placed  at  some  little  dis- 
tance behind  the  first,  and  all  ends  of  rubber  and  silk  ligatures  are 
cut  short. 

Another  way  of  securing  the  elastic  ligature  is  to  have  an  assistant 
lay  the  silk  ligature  on  the  top  of  the  first  half  hitch  of  the  knot  at 
right  angles  to  the  elastic  ligature :  next,  to  tie  this  with  a  second 
hitch ;  and,  finally,  to  tie  the  silk  ligature  across  this  second  crossing 
of  the  elastic  ligature. 

Next,  the  uterus  is  cut  off  one  and  a  half  to  two  inches  above  the 
elastic  ligature,  and  the  peritoneal  covering  of  the  stump  stitched 
with  a  fine  curved  needle  and  a  continuous  catgut  suture  to  the  peri- 
toneum near  the  lower  end  of  the  abdominal  incision,  under  the  liga- 
ture, so  as  to  close  the  peritoneal  cavity.  The  remaining  peritoneal 
edges  are  stitched  together,  and  the  abdominal  wound  closed  as  in 
other  laparotomies,  leaving  a  circular  furrow  formed  of  the  receding 

1  James  R.  Goffe  of  New  York,  Amer.  Jour.  Obst.,  1890,  vol.  xxiii.  No.  4,  p.  372  ; 
ibid.,  Aug.,  1895,  vol.  xxxii.  p.  180;   Chrobak  of  Vienna,  Centralbl.  f.  Gynak.,  1891, 
vol.  xv.  p.  715;  Besselmann,  ibid.,  p.  939;  B.  F.  Baer  of  Philadelphia,  Amer.  Jour. 
Obst.,  Oct.,  1892,  vol.  xxvi.  p.  489. 
32 


498  DISEASES  OF  WOMEN. 

muscular,  fascial,  adipose,  and  cutaneous  layers  of  the  abdominal 
wall. 

The  stump  of  the  uterus  is  transfixed  with  a  pair  of  steel  pins 
crossing  one  another  at  right  angles  above  the  ligature.  Small  caps 
are  pushed  over  the  points  in  order  to  protect  the  skin.  The  cut 
surface  and  the  cervical  canal  are  seared  with  Paquelin's  cautery,  and 
covered,  as  well  as  the  surrounding  furrow,  with  a  mixture  of  3  parts 
of  tannin  with  1  part  of  salicylic  acid.  Finally,  the  whole  is  dressed 
as  after  a  common  laparotomy,  and  the  dressing  need  not  be  changed 
for  eight  or  ten  days,  when  the  sutures  are  removed. 

It  is  not  rare  that  a  bloody  discharge  from  the  vagina  appeal's  three 
or  four  days  after  the  operation.  It  is  without  importance. 

The  stump  falls  off  after  fifteen  to  twenty  days,  leaving  a  deep 
funnel-shaped  depression,  the  necrosis  extending  beyond  the  elastic 
ligature.  This  funnel  is  dressed  with  iodoform  gauze,  which  is 
changed  daily  until  the  surface  is  healed. 

In  leaving  the  above-described  furrow  free  between  the  pedicle  and 
the  abdominal  wall,  except  the  peritoneum,  a  great  source  of  infection 
and  death  has  been  eliminated,  but,  on  the  other  hand,  a  weak  point 
is  left  in  the  abdominal  wall,  and  it  is  necessary  for  the  patient  to 
wear  an  abdominal  belt. 

If  the  ovaries  are  left  behind,  it  happens  occasionally  that  the  men- 
strual flow  continues  through  the  pedicle. 

This  method  is  not  applicable  to  tumors  that  have  not  risen  up 
from  the  pelvic  into  the  abdominal  cavity ;  it  entails  a  tedious  conva- 
lescence ;  and  it  exposes  the  patient  to  ventral  hernia ;  but  it  is  expe- 
ditious and  convenient  in  dealing  with  very  large  tumors. 

Comparison  between  Total  Extirpation  and  Sup)°avaginal  Amputa- 
tion of  the  Uterus. — For  the  treatment  of  fibroids,  in  which  the  cervix, 
or  at  least  the  lowest  part  of  it,  is  healthy  supravaginal  amputation 
is  preferable  to  the  total  extirpation.  There  is  hardly  any  hemorrhage, 
while  in  the  total  extirpation,  at  least  when  the  whole  operation  is 
performed  from  above,  there  is  often  toward  the  end  of  the  operation 
a  troublesome  hemorrhage  from  an  artery  hard  to  find  and  to  secure  at 
the  bottom  of  the  deep  wound.  The  supravaginal  amputation  is  easier 
and  can  be  performed  in  less  time.  The  stumps  of  the  broad  ligaments 
and  the  roof  of  the  vagina  hold  one  another,  so  that  there  is  no  danger 
of  prolapse  of  the  vagina,  as  in  certain  methods  of  total  extirpation,  nor 
any  danger  of  vaginal  hernia  (p.  334),  which  occasionally  has  been 
observed  after  total  extirpation.  The  vagina  retains  its  depth,  while 
sometimes  it  is  shortened  in  the  rival  operation. 

There  are  numerous  modifications  of  these  myoma-operations  upon 
which  the  scope  of  this  work  does  not  allow  us  to  enter. 

Abdominal  Enudeation. — A  fibroid  may  be  enucleated,  that  is  to 
say,  separated  from  the  surrounding  tissue  and  removed,  from  the 


DISEASES  OF  THE   UTERUS.  499 

broad  ligaments,  from  the  pelvic  floor,  or  from  the  substance  of  the 
uterus. 

A.  Enucleation  from  the  Broad  Ligaments. — If  possible,  it  is  a  pre- 
caution against  bleeding  to  tie  the  ovarian  and  uterine  arteries.     But 
even  without  this  a  transverse  incision  is  made  through  the  peritoneum 
over  the  whole  tumor.     The  peritoneum  is  stripped  back  with  the 
finger,  and  a  volsella  inserted  into  the  tumor,  which  is  pulled  up- 
ward.   As  a  rule,  the  tumor  is  enucleated  without  a  pedicle ;  in  other 
cases  the  tube  or  the  substance  of  the  uterus  forms  one,  which  is  tied 
and  cut.  The  enucleation  should  be  performed  from  above  downward 
and  from  the  wall  of  the  pelvis  toward  the  uterus,  so  as  to  avoid  the 
ureter  and  have  the  uterine  artery  in  the  pedicle  if  there  is  one. 

A  large  cavity  is  left,  that  may  be  dealt  with  in  different  ways. 

1.  A.  Martin's  method  is  to  perforate  the  bottom  so  as  to  enter  the 
vagina  with  a  forceps  which  is  pushed  through  to  the  vulva.     Here 
a  seft-rubber  T-shaped  drainage-tube  is  seized,  and  pulled  up  till  the 
transverse  bar  lies  in  the  bed  of  the  tumor.     Then  the  peritoneum  is 
stitched  together. 

2.  Fritsch's  method  is  to  cut  off  redundant  tissue,  stitch  the  edge  of 
the  pouch  to  the  edges  of  the  abdominal  wound,  and  fill  the  pouch 
with  iodoform  gauze  disposed  like  a  fan,  which  serves  both  to  check 
hemorrhage  and  to  secure  drainage. 

Another  way  of  packing  the  iodoform  gauze  is  that  of  Mikulicz : 
a  large  piece  of  gauze  with  a  strong  silk  thread  attached  to  the 
middle  is  introduced  into  the  cavity  to  be  compressed,  and  is  filled 
with  strips  of  gauze  like  a  bag.  After  a  day  the  interior  strips  are 
withdrawn,  and  finally  the  outer  piece  is  removed  by  pulling  on  the 
silk  thread. 

If  it  is  not  possible  to  stitch  the  sac  to  the  abdominal  wall,  it  is 
stuffed  with  iodoform  gauze,  the  peritoneum  closed  over  it  with  a 
tobacco-pouch  suture,  an  incision  made  in  the  vagina,  and  the  end  of 
the  gauze,  which  has  been  marked  beforehand  by  attaching  a  silk 
thread  to  it,  pulled  a  little  down  into  the  vagina.  In  both  cases  the 
vagina  is  solidly  tamponed  with  iodoform  gauze. 

3.  A  third  method  (Hofmeier's)  is  to  stop  hemorrhage  by  stitching 
the  bleeding  places  with  a  continuous  catgut  suture,  and  let  the 
walls  of  the  wound  fall  together.     Sometimes  it  suffices  to  touch  the 
bleeding  spots  with  Monsel's  solution. 

It  is  also  advisable  to  throw  an  elastic  ligature  around  the  cervix 
as  soon  as  feasible,  or  around  the  lower  part  of  the  tumor,  so  that  a 
part  of  it  may  be  cut  off,  which  facilitates  the  removal  of  the  remain- 
der (so-called  morcellation). 

B.  Enucleation  from  the  pelvic  floor,  under  the  broad  ligament,  is 
still  more  difficult  and  dangerous.     It  is  carried  out  according  to  the 
same  principles  as  for  intraligamentous  tumors. 


500  DISEASES  OF  WOMEN. 

C.  Enucleation  from  the  Uterus. — When  a  fibroid  is  shelled  out  of 
the  body  of  the  uterus,  a  capsule  is  left,  the  walls  of  which  are  hard 
to  bring  together  with  sutures.  The  results  have  been  so  little  satis- 
factory that  other  operations  are  preferred. 

Small  tumors  springing  from  the  cervix  or  the  lower  uterine  seg- 
ment can  sometimes  be  enucleated  from  the  vagina,  either  by  posterior 
colpotomy,  as  in  the  first  step  of  vaginal  hysterectomy  (p.  483),  or  by 
anterior  colpotomy,  as  described  in  treating  of  vaginal  hysteropexy 
(p.  450). 

Complication  with  Pregnancy. — Fortunately,  most  women  with 
fibroids  are  sterile,  and  if  they  conceive,  their  pregnancy  quite  fre- 
quently ends  in  abortion  or  in  premature  labor.  Labor  at  term  may 
be  easy,  but  oftener  the  fibroid  proves  a  dangerous  complication.  If 
we  are  consulted  as  to  the  advisability  for  a  woman  afflicted  with  a 
fibroid  of  the  uterus  to  contract  marriage,  it  is,  as  a  rule,  best  to  dis- 
suade her  from  it.  Pregnancy  having  occurred,  it  is  in  harmony  with 
nature's  own  method  to  induce  abortion  or  premature  labor,  if  the 
tumor  is  situated  in  such  a  place  or  has  such  proportions  that  great 
trouble  may  be  anticipated  by  allowing  gravidity  to  go  on  till  full 
term. 

To  perform  operations  during  pregnancy  will  be  likely  to  lead  to 
abortion.  Unless  there  be  urgent  symptoms,  such  as  hemorrhage  or 
pressure,  it  is  better  to  delay  operative  interference  till  labor  sets  in. 
A  pedunculated  subserous  tumor  may  sometimes  be  pushed  up  out  of 
the  way  of  the  child.  A  cervical  tumor  may  be  enucleated,  and  on 
account  of  the  succulence  of  the  womb  and  the  uterine  contractions 
present,.,  the  enucleation  is  both  easier  and  safer  than  under  ordinary 
circumstances.  But  if  the  tumor  extends  high  up,  it  may  be  neces- 
sary to  perform  Cesarean  section  or  Porro's  operation  or  to  sacrifice 
the  child. 

If  the  child  has  been  born,  it  is  better  to  postpone  the  consideration 
of  operation,  so  much  more  so  as  we  have  seen  that  the  tumor  may 
disappear  during  involution. 

Sloughing. — For  some  gynecologists  the  appearance  of  sloughing 
in  a  sessile  fibroid  is  an  indication  for  hysterectomy.  Taking  into 
consideration  the  unfavorable  condition  in  which  that  grave  operation 
would  have  to  be  performed,  and  the  case  referred  to  above  (p.  481), 
I  am  inclined  to  think  a  more  palliative  treatment  is  preferable, 
especially  if  septicemia  has  already  developed. 

Mortality. — In  deciding  the  question  of  the  advisability  of  per- 
forming cutting  operations  for  the  removal  of  fibroids  we  should  bear 
in  mind  that  the  disease  for  which  they  are  to  be  performed  rarely 
leads  to  death ;  that,  as  a  rule,  improvement  takes  place  after  the 
menopause ;  and  that,  on  the  other  hand,  the  operation  is  followed 
by  a  large  mortality.  Until  the  last  decade  euucleation  from  the  cervix 


DISEASES  OF  THE   UTERUS.  501 

had  a  mortality  of  from  15  to  20  per  cent. ;  hysterectomy,  with  extra- 
peritoneal  treatment  of  the  pedicle,  25  per  cent. ;  with  intraperitoneal 
treatment  of  the  pedicle,  33  per  cent. ;  and  in  cases  of  extensive  enu- 
cleation  from  the  broad  ligaments  and  the  pelvic  floor  the  death-rate 
was  even  57  per  cent.1  But  constant  progress  is  being  made,  and  sev- 
eral operators  have  of  late  reported  runs  of  a  score  of  hysterectomies 
without  a  death.  It  would  not  do  for  the  average  operator  and  still 
less  for  the  beginner  to  expect  results  like  those  of  P6an  and  Tait, 
who  have  reduced  their  mortality  to  1.5  per  cent.  The  mortality 
among  good  American  operators  ranges  now  between  5  and  6  per 
cent.2 

Causes  of  Death. — Death  after  fibroma-operations  is  due  to  shock, 
hemorrhage,  septicemia,  embolism,  intestinal  obstruction,  ligation  of 
the  ureters,  or  tetanus. 

Shock  plays  a  very  great  role  in  operations  that  often  are  very  pro- 
tracted,3 and  in  which  the  abdominal  organs  are  exposed  to  much 
handling.  The  danger  is  so  much  greater  as  sometimes,  in  conse- 
quence of  the  presence  of  the  fibroid  or  its  treatment  by  ergot,  the 
patient  has  a  weak  heart.  In  order  to  avoid  shock,  the  patient 
should  be  kept  warm  during  the  operation,  in  which  respect  the 
above-mentioned  woollen  leggings  (p.  197)  may  be  of  use.  The 
operation  should  be  simplified,  and  performed  as  rapidly,  as  possible. 
The  intestines  should  not  be  exposed  or  handled  more  than  absolutely 
necessary,  which  is  much  facilitated  by  the  Trendelenburg  posture. 
Ether  should  be  used  for  anesthesia.  When  the  heart  flags,  hypo- 
dermic injections  of  tincture  of  digitalis  or  nitro-glycerin  (p.  210) 
should  be  given. 

Hemorrhage  is  now  controlled  much  better  than  formerly  by  means 
of  pressure-forceps  and  the  elastic  ligature.  If  the  intra-abdominal 
treatment  of  the  pedicle  is  used,  internal  hemorrhage  may  take  place 
after  the  operation  is  finished.  This  dangerous  condition  makes  itself 
known  by  the  restlessness  of  the  patient,  a  weak,  frequent  pulse, 
pallor,  a  cold,  clammy  skin,  a  swelling  of  the  abdomen,  and  sometimes 

1  Complete  statistical  tables  are  found  in  "  A  Eeview  of  the  Operation  of  Gastrot- 
omy  for  Myofibroma,"  by  H.  E.  Bigelow  of  Washington,  D.  C.,  in  Amer.  Jour.  Obzt., 
1883-84.     Geo.  W.  Johnston  of  Washington,  D.  C.,  has  collected  a  large  number  of 
cases  of  fibromata  of  the  cervix,  Amer.  Jour.  Obst.,  1885,  vol.  xviii.  p.  1280.     (See  also 
"Analysis  of  Some  Statistics  on  Supravaginal  Hysterectomy,"  by  Marie  B.  Werner, 
Annals  of  Gynecology,  Oct..  1892,  vol.  vi.  p.  56.) 

2  Chas.  P.  Noble,  Med.  and  Surg.  Reporter,  June  2,  1894,  publishes  the  following 
table: 

Kelly 57  cases 2  deaths. 

Baer 57     "      3      " 

Polk 40     "      3      " 

Noble J14    "      _!_     " 

Total 168  cases 9  deaths  —  5.36  per  cent. 

3  Plan's  operations  have  often  taken  three  hours.     (Pe"an  et  Urdy,  "Hyste'roto- 
mie,"  Paris,  1873.) 


502  DISEASES  OF  WOMEN. 

a  distinct  feeling  of  the  warm  fluid  being  poured  out  into  the  abdom- 
inal cavity.  Under  such  circumstances  the  only  means  of  rescue  is 
speedily  to  reopen  the  abdomen,  clean  out  the  cavity,  find  the  source 
of  hemorrhage,  tie  the  bleeding  vessel  or  put  in  additional  sutures, 
inject  a  pint  of  hot  water  into  the  rectum  or  inject  a  warm  saline 
solution  (common  salt  a  little  over  J  per  cent,  will  do)  into  a  vein, 
into  the  peritoneal  cavity,  or  under  the  skin.  The  best  place  for  this 
subcutaneous  injection  is  under  the  clavicle  :  .liij-vj  are  injected  every 
ten  or  fifteen  minutes,  until  at  least  §xxiv  have  been  injected.  For 
any  of  these  injections  an  apparatus  which  I  described  in  1878,  and 
have  used  several  times  with  success,  will  be  found  convenient.  It 


Garrigues'  Transfusion  Apparatus :  A,  plunger ;  B,  bulb;  C,  stopcock ;  D,  flexible  probe- 
pointed  canula ;  E,  E,  valves. 

is  essentially  a  fine  Davidson  syringe1  (Fig.  274).  In  the  subcu- 
taneous injection  a  hollow  needle  is  substituted  for  the  blunt  flexible 
canula.  Bottles  with  hot  water  are  applied  all  around  the  patient, 
the  extremities  are  rubbed,  and  stimulants  are  used  freely. 

Septieemia  may  be  due  to  the  entrance  of  pathogenic  germs  during 
the  operation,  to  the  use  of  insufficiently  disinfected  materials,  and 
to  infection  from  the  pedicle,  or  perhaps  even  from  the  intestine.2 
The  more  bacteriology  progresses,  the  more  difficult  it  seems  to  guard 
against  infection. 

Thrombosis  beginning  in  the  pelvic  veins  may  extend  to  those  of 
the  thigh,  and  from  the  thrombus  a  piece  may  be  detached  and  form 
an  embolus. 

Intestinal  Obstruction  may  be  brought  about  by  exudation  and 
adhesions.  The  means  to  avoid  it  are  in  supravaginal  hysterectomy 
to  lift  the  intestines  up  before  dropping  the  pedicle,  to  avoid  as  far  as 
possible  leaving  raw  surfaces  in  the  abdominal  cavity,  and  to  move 
the  bowels  early.  (See  Ovariotomy.)  If  obstruction  sets  in,  it  should 
be  combated  with  large  injections  of  lukewarm  water  from  a  fountain 

1  Garrigues,  "  Apparatus  for  Transfusion,"  Amer.  Jour.  Obst.,  October,  1878,  vol. 
xi.  No.  4,  p.  754. 

2  Welch,  "Wound  Infection,"  Amer.  Jour.  Med.  Scl,  Nov.,  1891,  p.  443. 


DISEASES  OF  THE   UTERUS.  503 

syringe.  The  enema  with  ox-gall,  described  on  p.  174,  may  also  be 
tried.  Lavage  of  the  stomach  with  a  weak  solution  of  salt,  sometimes 
combined  with  the  administration  of  castor  oil,  has  proved  very  effec- 
tive. (See  Ovariotomy.)  If  the  obstruction  remains,  the  abdomen 
must  be  reopened  and  the  obstacle  removed  manually. 

The  ligation  of  one  or  both  ureters  leads  to  acute  hydronephrosis 
and  vomiting.  If  thirty-six  hours  have  elapsed  since  the  operation, 
there  would  be  little  danger  of  hemorrhage  in  removing  the  ligatures 
on  the  uterine  arteries,  which  are  likely  to  be  those  that  include  the 
ureters.  The  situation  being  desperate,  it  might  be  worth  trying  this 
heroic  remedy. 

Tetanus  is  an  exceedingly  rare  complication,  and  its  treatment  is 
probably  hopeless.  An  attempt  should,  however,  be  made  with 
bromide  of  potassium,  chloral  hydrate,  curare,  and  the  new  serum- 
therapy. 

Indications  for  Operative  Interference. — Polypi  should  always  be 
removed,  at  least  when  they  become  easily  accessible.  Subperitoneal 
fibroids  with  a  thin  pedicle  should  be  removed  if  they  annoy  the 
patient  or  grow  much.  Fibro-cystic  and  suppurating  tumors  must  be 
removed.  In  all  other  cases  Apostoli's  treatment  should  be  employed, 
and  operations  only  resorted  to  in  those  in  which  it  fails  or  when  it 
cannot  be  obtained.  When  a  fibroid  grows  in  spite  of  medical  and 
electric  treatment,  it  or  the  uterus  containing  it  should  be  removed  as 
soon  as  possible. 

In  regard  to  fibro-cysts,  it  may  be  safer  to  desist  from  a  total  extir- 
pation, and  only  to  make  a  large  incision,  evacuate  the  fluid,  stitch  the 
sac  to  the  abdominal  wound,  and  pack  it  with  iodoform  gauze.  It 
will  then  shrink,  and  be  filled  by  granulation. 

D.  Sarcoma. 

Under  the  vague  name  of  cancer  are  united  neoplasms  of  different 
anatomical  structure,  having  this  in  common,  that  they  undermine 
the  constitution  and  sooner  or  later,  in  most  cases  rapidly,  lead  to 
death. 

To  this  group  belong  sarcoma,  carcinoma,  malignant  adenoma, — 
the  last  being  only  the  first  stage  of  some  cases  of  carcinoma, — and 
certain  papillomas. 

Sarcoma. — Pathological  Anatomy. — Sarcoma  preferably  affects  the 
body  of  the  uterus.  In  the  neck  it  is  very  rare.  It  appears  in  three 
forms — the  circumscinbed,  the  diffuse,  and  the  papillary  sarcoma.  The 
circumscribed  forms  globular  tumors  like  fibroids,  and  used  to  be 
called  recurrent  fibroid,  because  it  developed  again  after  extirpation, 
which  a  genuine  fibroid  never  does.  Like  a  fibroid,  it  may  be  sub- 
mucous,  intramural,  or  subperitoneal,  and  it  may  form  a  polypus. 
It  has  very  rarely  a  capsule.  Its  consistency  is  generally  soft  and 


504  DISEASES  OF  WOMEN. 

brain-like,  but  it  may  be  as  dense  as  a  fibroid.  It  may  start  from 
the  mucous  membrane,  the  muscular  tissue,  or  the  peritoneum.  Often 
it  has  its  origin  in  a  myoma. 

The  diffuse  sarcoma  starts,  as  a  rule,  from  the  submucous  connective 
tissue,  invades  the  mucous  membrane,  and  may  spread  more  or  less 
deeply  into  the  muscular  tissue  of  the  uterus  or  perforate  the  whole 
wall,  so  as  to  form  a  tumor  in  the  abdominal  cavity.  It  is  composed 
of  a  whitish  or  grayish  extremely  vascular  mass. 

Most  sarcomas  have  a  fasciculated  arrangement,  bands  of  fibrous 
connective  tissue  separating  groups  of  cells — a  disposition  which  may 
even  be  seen  macroscopically  by  breaking  hardened  specimens.  The 
less  fibrous  tissue  they  contain,  and  the  more  the  cells  predominate, 
the  more  malignant  they  are.  In  younger  portions  of  the  growth  a 
jelly-like  amorphous  mass  is  found  between  the  fibrillse  which  later 
disappears.  The  cells  may  be  spindle-shaped  or  round.  Sometimes 
also  so-called  giant-cells  with  many  nuclei  are  interspersed  among  the 
others.  The  sarcomatous  tissue  is  full  of  enormously  dilated  capillaries 
with  very  thin  walls,  which  explains  the  hemorrhages  that  form  so 
prominent  a  feature  among  the  symptoms. 

The  diffuse  sarcoma,  as  a  rule,  contains  epithelial  cells,  so  that  a 
transition  is  made  to  carcinoma. 

In  myxo-sarcoma,  also  called  colloid  cancer,  there  is  a  preponderance 
of  the  intercellular  amorphous  substance  containing  muciu,  to  which 
is  due  its  gelatinous  consistency. 

Papillary  sarcoma  starts  from  the  vaginal  portion  of  the  uterus. 
It  arises  from  a  hypertrophy  of  the  papilla3  of  the  mucous  membrane, 
consists  of  fusiform  or  round  cells,  and  has  a  hydropic  intercellular 
substance. 

Sarcomas  may  spread  to  the  neighboring  organs — the  vagina,  the 
bladder,  and  the  abdominal  cavity.  They  may  also  give  rise  to 
metastatic  deposits  at  distant  places,  such  as  the  vagina,  lymphatic 
glands,  the  connective  tissue  of  the  pelvis,  the  peritoneum,  the  liver, 
the  lungs,  the  pleura,  the  vertebrae,  and  the  skin. 

A  sarcoma  may  become  cystic,  and  is  then  called  cysto-sarcoma.1 

Etiology. — The  cause  of  sarcoma  is  unknown.  It  is  most  common 
at  the  climacteric  age,  between  forty  and  fifty  years,  but  differs  from 
carcinoma  by  being  found  in  persons  under  twenty  years  of  age,  so 
that  it  may  be  called  the  cancer  of  youth.  It  may  even  be  congenital. 
It  differs  likewise  from'  carcinoma  in  this  respect,  that  among  those 
affected,  with  it  many  are  sterile,  while  carcinoma  is  rarely  found  in 
women  who  have  never  borne  children.  It  sometimes  follows  endo- 
metritis  or  develops  in  a  fibroid. 

1  I  have  described  and  represented  in  the  New  York  Medical  Journal,  August,  1 882, 
such  a  case  in  which  the  mucous  membrane  of  the  uterus  was  intact,  but  a  large 
tumor  composed  of  cysts  and  solid  masses  had  been  developed  in  the  abdomen. 


DISEASES   OF  THE   UTERUS.  505 

Symptoms. — In  the  beginning  the  symptoms  hardly  differ  from  those 
of  fibroid  tumors — namely,  menorrhagia,  metrorrhagia,  leucorrhea, 
hydrorrhea,  and  pain.  The  uterus  may  be  enlarged  and  nodular,  and 
may  become  inverted.  But  the  growth  is  a  rapid  one.  There  is  soon 
established  a  continuous  sero-sanguinolent  discharge  with  offensive 
smell.  The  patient  becomes  emaciated,  exsanguinated,  and  weak,  and 
has  an  ashy  color — a  complex  of  symptoms  called  cachexia.  The 
cervix  often  becomes  dilated.  Pieces  of  a  soft  brain-like  mass  may  be 
expelled  from  the  interior  of  the  womb.  The  pain  may  be  due  to 
pressure  or  to  the  nature  of  the  disease.  Sometimes  it  is  expulsive  in 
character.  The  finger  introduced  after  dilatation  of  the  cervix  feels 
the  soft  mass  in  the  wall  of  the  uterus. 

Diagnosis. — The  diagnosis  of  sarcoma  is  by  no  means  always  an 
easy  matter.  An  intramural  sarcoma  offers  the  same  symptoms  as  a 
fibroid  similarly  situated.  The  sarcomatous  degeneration  of  the 
mucous  membrane  is  somewhat  more  characteristic  by  the  rapid  dis- 
integration that  takes  place  and  the  speedy  development  of  cachexia. 
The  appearance  of  a  tumor  like  a  fibroid  at  the  time  of  the  meno- 
pause, and  its  growth  after  the  same,  and  hemorrhage  recurring  after 
the  menopause,  must  awaken  a  suspicion  of  its  sarcomatous  nature. 
A  sero-sanguinolent  discharge,  the  softness  of  the  tumor, — which 
often  allows  the  finger  to  penetrate  it  or  break  pieces  off  from  it, — a 
more  agonizing  pain,  and  the  rapid  emaciation  and  cachexia,  are  all 
characteristic  of  sarcoma.  In  regard  to  softness,  we  must,  however, 
remember  that  it  is  likewise  found  in  a  gangrenous  fibroid. 

From  hyperplastie  endometritis  it  is  differentiated  by  greater  tender- 
ness of  the  body,  by  the  often  open  cervical  canal,  by  sometimes 
forming  a  polypus  that  hangs  out  through  the  cervix,  by  the  appear- 
ance of  cachexia,  and  by  the  spontaneous  expulsion  of  torn-off  pieces 
of  the  tumor,  which  never  takes  place  in  endometritis.  Particles  ob- 
tained by  curetting,  on  the  other  hand,  are  deceptive :  a  sarcoma  may 
furnish  a  specimen  exclusively  composed  of  healthy  mucous  mem- 
brane, while  in  endometritis  the  curette  may  bring  away  granulation 
tissue  that  looks  entirely  like  small  round-cell  sarcoma.  The  clinical 
diagnosis  is,  therefore,  more  reliable  than  the  microscopical,  but  one 
may  corroborate  the  other,  and  sometimes  the  presence  of  large  cells 
separated  by  intercellular  basis  substance  is  conclusive. 

As  long  as  the  epithelial  cells  of  the  utricular  glands — either  origi- 
nal or  of  new  formation — are  unchanged,  the  diagnosis  of  chronic 
endometritis  is  admissible,  whatever  the  nature  of  the  interstitial 
tissue  be.  As  soon,  on  the  contrary,  as  the  regular  arrangement  of 
the  epithelial  cells  is  broken  up,  and  they  give  way  to  sarcomatous 
tissue,  the  diagnosis  of  sarcoma  can  be  made.1 

When  a  wfhole  tumor  is  removed,  its  nature  may  be  settled  by  the 

1  L.  Heitzmann,  Amer.  Jour.  Obst.,  1887,  vol.  xx.  pp.  906,  907. 


506  DISEASES  OF  WOMEN. 

microscope;  and  if  it  is  reproduced  in  the  same  place  or  forms 
metastases,  its  sarcomatous  nature  is  proved. 

In  this  connection  it  must,  however,  be  remembered  that  endome- 
tritis  may  produce  new  fungoid  growths  after  curetting,  and  that 
another  myoma  may  develop  in  another  place  after  one  has  been  re- 
moved. 

The  differentiation  from  carcinoma  of  the  body  may  be  impossible, 
and,  as  we  have  seen  above,  the  two  are  frequently  mixed  in  the 
diffuse  form.  The  discharge  in  sarcoma  is  less  fetid ;  ulceration  does 
not  appear  so  soon ;  extension  to  the  neighborhood  is  slower,  and 
sarcoma  may  form  a  polypus  emerging  from  the  os,  which  carcinoma 
never  does. 

Prognosis. — The  prognosis  is  bad.  The  disease  ends  in  death,  on 
an  average,  in  about  three  years,  sometimes  as  rapidly  as  four  months, 
and  very  exceptionally  as  late  as  ten  years. 

Treatment. — On  account  of  the  immense  danger  to  health  and  life, 
the  best  treatment,  when  once  the  diagnosis  is  certain,  is  to  perform 
the  total  extirpation  of  the  uterus,  either  by  the  vaginal,  the  abdom- 
inal, or  the  combined  method  (pp.  483-496).  Morcellation  should 
not  be  thought  of,  on  account  of  the  danger  of  infecting  the  neighbor- 
ing tissue  during  the  operation.  Even  if  the  cervix  is  healthy  the 
whole  organ  should  be  removed. 

Since  the  development  of  sarcoma  is  slower  and  does  not  implicate 
the  surrounding  parts  so  soon  as  carcinoma  does,  the  operation  is 
oftener  indicated  than  in  the  latter  disease,  and  the  prognosis  as  to 
complete  recovery  is  considerably  better. 

A  polypoid  sarcoma  may  be  cut  off  and  the  base  cauterized.  If  a 
radical  operation  is  impossible,  a  palliative  treatment,  similar  to  that 
for  carcinoma,  especially  curetting  followed  by  cauterization  with  the 
thermo-  or  galvano-cautery  or  nitric  acid,  and  the  application  of 
diluted  liquor  ferri  chloridi  (1  to  10  parts  of  water),  should  be  insti- 
tuted. 

In  handling  sarcomas  great  care  should  be  taken  to  avoid  mechan- 
ical infection  of  yet  healthy  parts. 

Decidual  Sarcoma. — Of  late  several  cases  have  been  described  of 
sarcoma  of  the  uterus  which  appeared  shortly  after  abortion  or  child- 
birth. The  tumors  were  composed  of  large  decidual  cells  imbedded 
in  a  mesh  work  of  connective  tissue,  forming  pseudo-alveoli  a"nd  con- 
taining nuclei  and  giant-cells.  The  affection  caused  increase  in  size 
of  the  uterus,  hemorrhage,  putrid  discharge,  metastatic  deposits  in  the 
iliac. fossae,  the  lungs,  and  other  organs;  and  ended  in  death  in  the 
course  of  from  six  to  seven  months. 

If  the  diagnosis  is  made  early  enough,  complete  ablation  of  the 
uterus  is  the  only  rational  treatment,  and  has  been  performed  success- 
fully. 


DISEASES  OF  THE   UTERUS. 


507 


E.   Carcinoma. 

Carcinoma  (Fig.  275)  is  a  neoplasm  composed  of  epithelial  cells 
often  grouped  in  alveoli  formed  of  connective  tissue,  with  a  tendency 
to  invade  neighboring  organs  and  undermine  the  constitution. 


FIG.  275. 


Cervical  Carcinoma  of  Uterus  extending  into  Body  :l  a,  body  of  uterus ;  6,  cervix ;  c,  tube ;  d, 
ovary  ;  e,  bydatid ;  /,  piece  of  wood  inserted  in  order  to  expose  the  cavity  of  the  uterus. 

Pathological  Anatomy. — Carcinoma  is  most  common  in  the  vaginal 
portion  of  the  uterus.  Next  in  frequency  is  that  of  the  cervix, 
while  that  of  the  body  is  comparatively  rare.  Upon  the  whole,  the 
uterus  is  very  frequently  aifected  in  this  way,  perhaps  oftener  than 
any  other  organ,  the  only  question  being  if  carcinoma  of  the  breast 
occurs  as  often  or  oftener. 

Carcinoma  of  the  Vaginal  Portion  begins  in  that  part  which  is 
covered  with  flat  vaginal  epithelium.  It  does  not,  however,  start 
directly  from  the  epithelium,  but  from  new-formed  glands,  and  may 
dip  deep  into  the  muscular  tissue  of  the  cervix  without  attacking  the 
cervical  mucous  membrane  or  the  outer  circumference.  It  may  also 
form  a  papillary  growth  which  develops  in  the  direction  of  the 

'  Specimen  from  iny  vaginal  hysterectomy  on  Mrs.  C.  C. ,  St.  Mark's  Hos- 
pital, March  25,  1891. 


508  DISEASES  OF  WOMEN. 

vagina,  and  may  become  so  large  as  to  fill  it  down  to  the  vaginal 
entrance.  From  its  shape  this  form  has  derived  the  name  of  cauli- 
flower excrescence.  A  third  form  is  that  of  a  flat  ulceration,  which 
has  been  described  under  the  name  of  rodent  ulcer. 

Cervical  carcinoma  begins  as  nodules  in  or  under  the  mucous  mem- 
brane of  the  cervical  canal,  which  coalesce  and  form  an  ulcer  on  the 
mucous  membrane,  whence  it  may  spread  outward,  forming  a  deep 
cavity  in  the  cervix  without  showing  at  the  os  or  invading  the  corpus. 
The  carcinomatous  degeneration  may  begin  in  the  glands  of  the  mucous 
membrane  or  in  the  connective  tissue. 

Carcinoma  of  the  Body  may  be  primary  or  secondary.  The  primary 
starts  from  the  epithelium  of  the  surface  or  from  the  glands.  It 
appears  in  a  diffuse  and  a  circumscribed  form,  the  latter  forming  a 
tumor,  which  may  become  pedunculated  so  as  to  form  a  polypus. 
Often  the  mucous  membrane  of  the  body  is  affected  at  an  early  date 
in  cases  of  carcinoma  of  the  cervix. 

In  regard  to  differences  in  structure,  several  varieties  of  uterine 
carcinoma  are  distinguished :  1,  epithelioma,  where  flat  or  cuboidal 
epithelial  cells  are  arranged  concentrically,  so  as  to  form  so-called  can- 
cer nests  or  pearls — a  form  probably  only  occurring  in  the  cervix ;  2, 
adenoid  carcinoma,  composed  of  columnar  epithelial  cells,  and  cha- 
racterized by  the  presence  of  tubular  formations,  with  manifold  con- 
volutions, arranged  in  groups  or  alveoli  or  exhibiting  a  plexiform 
arrangement,  the  epithelial  cells  often  breaking  up  into  medullary 
corpuscles ;  3,  medullary  carcinoma,  where  the  cellular  element  pre- 
dominates, forming  a  soft  mass ;  and  4,  scin'hous  or  Jibrous  carcino- 
ma, in  which  there  are  larger  trabeculaB  of  fibrous  connective  tissue, 
imparting  greater  hardness  to  the  growth.  Of  these  varieties  the 
medullary  is  the  one  that  grows  fastest  and  soonest  leads  to  a  fatal 
issue. 

Carcinoma  of  the  uterus  extends  to  neighboring  parts,  especially 
the  vagina,  the  bladder,  the  pelvic  connective  tissue,  the  tubes  and 
ovaries,  the  peritoneum,  the  rectum,  and  very  rarely  the  bones  of  the 
pelvis.  When  ulceration  takes  place,  a  vesico-uterine  fistula  may  be 
formed,  or,  more  rarely,  a  rectovaginal  fistula.  The  internal  iliac,  sacral 
and  lumbar,  or  the  obturator  and  inguinal  glands  become  infiltrated  ac- 
cording to  the  part  of  the  uterus  that  is  affected  (p.  62).  Of  the  above- 
named  varieties,  the  epithelioma  is  least  apt  to  spread  to  the  glands.  If 
the  bones  are  affected,  the  growth  may  enter  the  hip-joint  and  dislocate 
the  femur;  the  tumor  may  compress  the  ureters,  causing  hydronephrosis. 

Compression  of  an  artery  may  be  followed  by  the  formation  of  an 
arterial  thrombus,  but  thrombi  are  much  more  commonly  found  in 
the  veins  of  the  pelvis  and  the  thighs.  They  may  be  due  to  direct 
pressure  or  be  caused  by  the  general  marasmus  and  weak  heart- 
action. 


DISEASES  OF  THE   UTERUS.  509 

Secondary  carcinoma  of  the  body  may  attack  the  uterus  by  exten- 
sion of  a  primary  carcinoma  from  the  bladder,  the  rectum,  the  ovary, 
or  the  peritoneum  of  Douglas's  pouch. 

Metastases  from  uterine  carcinoma  are  rare,  but  have  been  found 
in  the  liver,  the  stomach,  the  lungs,  pleurae,  kidneys,  the  peritoneum, 
the  brain,  and  other  parts. 

Etiology. — Carcinoma  of  the  uterus  is  a  disease  of  advanced  age. 
It  is  very  rarely  found  below  the  age  of  twenty,  in  which  respect 
it  differs  from  a  sarcoma.  It  is  most  common  during  the  first  five 
years  following  the  menopause.  It  is  much  more  frequent  in  the 
lower  classes  than  in  the  higher  walks  of  society,  probably  because 
poor  women,  as  a  rule,  have  more  frequent  childbirths,  because  they 
are  much  less  cleanly,  and  because  worry  and  want  favor  the  malig- 
nant degeneration. 

It  is  to  some  extent  hereditary,  and  is  frequently  found  in  families 
other  members  of  which  are  tuberculous.  Perhaps  also  syphilis  in 
ancestors,  by  giving  rise  to  a  deteriorated  constitution,  may  predispose 
to  it. 

Carcinoma  of  the  neck  is  usually  found  in  women  who  have  borne 
a  large  number  of  children  or  had  difficult  labors.  Lacerations  of 
the  cervix  (p.  396),  with  the  concomitant  eversion,  glandular  devel- 
opment, and  erosions,  are  apt  to  become  the  starting-point  of  it. 
Carcinoma  of  the  body,  on  the  other  hand,  is  comparatively  com- 
mon in  nulliparous  women.  Benign  tumors  may  in  the  course  of 
time  become  carcinomatous. 

It  has  been  very  generally  repeated  that  while  the  negro  race  was 
much  more  liable  to  fibroma  of  the  uterus  than  white  people,  it  was 
free  from  carcinoma.  The  first  is  denied  by  a  competent  judge,  and 
the  latter  disproved  by  the  public  statistics  for  fourteen  consecutive 
years  of  the  city  of  Charleston,  S.  C.,  which  shows  that  there  is 
hardly  any  difference  between  the  two  races.1 

Symptoms. — The  first  symptom  that  brings  the  patient  to  seek  advice 
is  loss  of  blood.  Often  it  is  only  a  slight  bleeding  following  coition. 
In  other  cases  it  is  a  return  of  bloody  discharge  after  the  menopause. 
In  others,  again,  the  menstrual  flow  becomes  too  abundant  or  pro- 
tracted, or  there  is  loss  of  blood  in 'the  intermenstrual  period. 

Another  early  symptom  is  a  common  leucorrheal  discharge  streaked 
with  blood.  Sometimes  a  shooting  pain  or  a  dull  ache  occurs  at  inter- 
vals in  the  sacral  or  hypogastric  region,  or  the  patient  may  have 
sciatica. 

If  the  carcinoma  is  developing  in  the  collurn,  we  in  most  cases 

find  a  laceration  with  eversion.     The  mucous  membrane  is  swollen, 

bleeds  easily,  and  contains  hard  nodules.     The  cervix  is  indurated  in 

its  totality,  and  not  only  at  the  angle  of  the  tear,  where  a  cicatricial 

1  Middleton  Michel,  Med.  News,  Oct.  8,  1892. 


510  DISEASES  OF   WOMEN. 

plug  (p.  397)  is  so  common  an  occurrence.  At  the  same  time,  the 
tissue  is  friable,  so  that  a  part  may  be  scraped  off  with  the  nail. 
Sometimes  the  uterus  is  tender  on  pressure. 

In  carcinoma  of  the  body  there  are  no  other  early  symptoms  than 
hemorrhage  and  leucorrhea. 

As  the  disease  progresses  these  symptoms  may  become  more 
marked  and  new  ones  are  added.  The  hemorrhage  often  becomes 
profuse.  After  nlceration  has  taken  place  there  is  at  times  a  profuse 
watery  discharge  with  a  penetrating,  most  disagreeable  odor,  and  in 
the  interval  a  fetid  muco-purulent  discharge.  The  pain  becomes 
more  constant  and  intense.  In  carcinoma  of  the  body  paroxysms  of 
expulsive  pain  are  caused  by  detached  pieces  of  the  neoplasm  which 
cannot  pass  out  through  the  closed  cervix.  Finally,  the  whole  body 
aches.  In  other  cases  the  pain  may  be  due  to  peritonitis  or  to  the 
direct  affection  of  the  nerves  in  the  uterus.  The  acrid  discharge  is 
apt  to  cause  pruritus  vulvse  and  excoriations  of  the  skin  on  the  inside 
of  the  thighs. 

In  some  cases  different  forms  of  dysuria  are  present.  Cystitis, 
causing  frequent  and  painful  micturition,  is  common.  If  one  of 
the  ureters  is  compressed  or  invaded  by  the  new  growth,  hydrone- 
phrosis  is  developed  on  the  corresponding  side.  The  amount  of 
urine  that  is  excreted  is  diminished.  The  patient  complains  of  pain 
in  the  lumbar  region,  nausea,  and  headache.  If  both  ureters  become 
obstructed,  complete  anuria  sets  in,  followed  by  uremic  convulsions 
and  death.  In  other  cases  the  uremic  symptoms  become  less  toward 
the  end,  the  obstruction  being  removed  by  the  extension  of  the  ulcer- 
ation. 

In  regard  to  the  alimentary  canal,  the  patient  frequently  complains 
of  a  bad  taste,  thirst,  loss  of  appetite,  eructations,  nausea,  vomiting, 
and  constipation.  The  hemorrhoidal  veins  surrounding  the  anus 
often  swell.  She  loses  flesh  and  strength,  and  her  skin  has  a  peculiar 
ashy  yellowish  hue. 

If  venous  thrombi  form  in  the  pelvis  and  thigh,  the  corresponding 
extremity  becomes  swollen  and  unwieldy. 

Sometimes  the  abdomen  is  swollen,  some  ascitic  fluid  may  collect, 
and  the  cutaneous  veins  in  the  abdominal  wall  become  distended. 
Peritonitis  is  of  frequent  occurrence.  Inflammation  of  the  lungs, 
pleura?,  and  kidneys  is  less  frequent.  Sometimes  dysentery  sets  in. 
A  detached  embolus  may  be  driven  into  the  pulmonary  artery  and 
put  a  sudden  stop  to  the  sufferings  of  the  patient.  Septicemia  is  rare, 
the  inflammatory  exudations  serving  as  a  barrier  against  the  entrance 
of  the  products  of  decay  into  the  circulation.  The  glands  in  the 
groins  and  in  the  depth  of  the  pelvis  are  felt  to  be  enlarged. 

By  vaginal  examination  we  find  the  uterus  to  be  immovable.  The 
vaginal  vault  is  as  hard  as  a  board.  From  the  cervix  we  may  find 


DISEASES  OF  THE   UTERUS.  511 

hanging  a  soft  polypoid  tumor,  which  may  fill  the  whole  vagina.  It 
is  friable  and  bleeds  easily.  Or  the  finger  enters  a  crater-shaped 
ulceration  surrounded  by  hard  walls.  Often  the  infiltration  with  car- 
cinomatous tissue  can  be  felt  as  hard  nodules  in  the  broad  ligaments 
or  as  a  hard  string  following  the  course  of  the  uterine  vessels  out  to 
the  pelvic  wall. 

Although  cancer  undoubtedly  is  transmissible  from  one  part  of  the 
body  to  another  with  the  current  of  the  vital  juices,  there  is  no  evi- 
dence that  it  can  be  inoculated  into  another  individual,  and  the  great 
rarity  of  carcinoma  of  the  penis  compared  with  the  very  common 
occurrence  of  the  disease  in  the  cervix  uteri  goes  far  to  show  that 
the  disease  is  not  transmissible  by  coition. 

Diagnosis. — A  sponge  left  in  the  vagina  and  forgotten  has  given 
rise  to  such  hemorrhage  and  offensive  discharge  that  it  has  been  taken 
for  a  cancerous  growth.  An  examination  with  the  finger  and  the 
eye  and  the  removal  of  the  foreign  body  will  soon  settle  that  error. 

The  distinction  from  erosions  may  be  difficult.  A  papillary  ulcer 
surrounded  by  follicles  is  likely  to  be  benign.  On  the  other  hand, 
we  find  in  carcinoma  of  the  cervix  a  sharp  line  of  demarkatiou  be- 
tween the  diseased  and  the  healthy  tissue :  the  former  is  elevated,  has 
a  yellowish  tint,  and  contains  glistening  yellowish-white  nodules. 
The  carcinomatous  tissue  is  more  friable  than  the  healthy  or  simply 
inflamed,  so  that  a  piece  may  be  broken  off  with  the  nail  of  the  exam- 
ining finger.  The  result  of  treatment  as  a  diagnostic  measure  is  valu- 
able :  erosions  heal  in  a  short  time  if  they  are  treated  with  sulphate  of 
copper  or  some  other  astringent  (p.  414),  whereas  carcinoma  spreads 
in  spite  of  the  treatment.  Microscopical  examination  may  be  entirely 
negative,  but  in  many  cases  it  gives  positive  information  in  regard  to 
the  malignancy  of  the  tissue.  For  this  purpose  a  wedge-shaped  piece 
must  be  cut  out  of  the  cervix,  choosing  the  most  affected  spot  and 
going  deep  enough  to  include  in  the  excision  part  of  the  muscular 
tissue.  The  wound  is  united  by  a  suture.  The  operation  is  so  little 
painful  that  general  anesthesia  is  superfluous.  A  strong  solution  of 
cocaine  may,  however,  be  applied  to  advantage.  The  excised  part 
should  be  hardened,  cut,  and  stained.  The  diagnosis  of  carcinoma  is 
only  warranted  if  atypical  epithelial  pegs  dip  into  the  muscular  tissue. 

A  carcinomatous  ulceration  must  be,  and  in  most  cases  is  easily, 
distinguished  from  the  other  kinds  of  ulcers  found  on  the  cervix 
(p.  424). 

Chancroid  is  an  acute  affection  characterized  by  sharp  edges,  a  yel- 
low bottom,  a  red  halo,  and  an  abundant  secretion  of  pus  of  a  different 
odor.  Chancre  may  give  rise  to  doubt,  but  the  history,  the  presence 
of  other  syphilitic  symptoms,  the  result  of  an  antisyphilitic  treatment, 
and  microscopical  examination  furnish  abundant  means  of  dispel- 
ling it. 


512  DISEASES  OF  WOMEN. 

Tuberculous  ulcers  are  surrounded  by  tuberculous  nodules ;  are,  as 
a  rule,  combined  with  tuberculosis  of  other  parts,  especially  the  lungs ; 
and  show  the  characteristic  bacillus. 

The  simple  friction  ulcer  found  where  the  cervix  protrudes  in  front 
of  the  vulva  is  surrounded  by  bluish  tissue,  and  heals  easily  under 
proper  care.  The  glands  are  not  affected. 

Corroding  ulcer l  has  not  so  hard  surroundings,  and  can  be  diagnos- 
ticated by  means  of  the  microscope,  which  shows  absence  of  epithelial 
proliferation. 

Papillary  hypertrophy  may  give  rise  to  small  benign  growths,  but 
they  have  a  narrow  base ;  when  seated  on  a  broad  base  a  papillary 
growth  is  carcinomatous. 

Carcinoma  of  the  body  has  to  be  differentiated  from  hyperplastic 
endometritis,  fibroma,  and  products  of  conception.  In  regard  to  hyper- 
plastic  endometritis  the  reader  is  referred  to  what  has  been  said  above 
(p.  411).  Here  we  will  only  add  a  few  words  about  the  microscopical 
examination.  The  diagnosis  of  scrapings  removed  by  the  curette  as 
being  carcinomatous  is  only  warranted  if  we  meet  with  encephaloid 
masses  which  show,  not  a  glandular  structure,  but  atypic  epithelial 
pegs.  Fungous  endometritis  is  characterized  by  the  presence  of  a 
varying  number  of  tubular  glands,  the  epithelium  of  which  is  un- 
broken. The  interglandular  tissue  may  be  crowded  with  lymph- 
corpuscles,  or  it  may  be  myxomatous  or  fibrous  in  character.2 

A  fibroid  follows  a  benign  course.  It  develops  very  slowly,  no 
particles  are  expelled,  there  is  no  bad  odor,  the  uterus  is  freely  mov- 
able, the  patient  has  no  fever,  and  her  constitution  does  not  suffer 
except  from  loss  of  blood.  She  may  be  pale,  but  she  has  not  the 
yellowish  color  of  carcinoma.  It  is  true,  a  fibroid  may  slough,  and 
then  there  may  be  high  temperature  and  fetid  discharge,  but  this  is 
a  condition  that  comes  on  suddenly,  and  ends  in  a  short  time  in  death 
or  recovery. 

Pieces  of  secundines  may  be  retained  in  the  uterus  for  years  and 
cause  considerable  hemorrhage,  pain,  and  leucorrhea.  When  they 
are  removed  with  the  curette  the  microscope  clears  the  diagnosis,  and 
the  patient  recovers. 

The  diagnosis  from  sarcoma  can  only  be  made  by  a  microscopical 
examination  of  expelled,  scraped-off,  or  excised  parts.  It  is  in  so  far 
of  importance  as  the  prospects  for  success  in  a  radical  operation  are 
greater  in  sarcoma  than  in  carcinoma. 

If  the  early  recognition  of  carcinoma  may  be  difficult,  in  its  ad- 

1  Corroding  ulcer  is  the  term  used  by  Dr.  Williams  for  the  one  he  ascribes  to  senile 
gangrene  caused  by  calcification  of  the  internal  iliac  arteries,  while  rodent  ulcer  is 
the  old  classical  name  that  may  yet  be  retained  for  very  flat  ulcerations  of  the 
vaginal  portion,  which  extend  very  slowly  to  the  sides,  and  very  late  dip  into  the 
depth  of  the  cervix,  but  are  microscopically  proved  to  be  carcinomatous. 

*  Louis  Heitzman,  Amer.  Jour.  Obst.,  September,  1887,  pi  919. 


DISEASES   OF  THE    UTERUS.  513 

vanced  stage  the  disease  presents  so  uniform  a  picture  that  it  is  easily 
recognized,  the  most  striking  features  being  the  hemorrhage,  the 
offensive  watery  discharge,  the  immobility  of  the  uterus,  the  implica- 
tion of  neighboring  organs,  the  crater-like  ulcer,  the  large,  friable, 
soft  mass  springing  from  it,  the  pains,  and  the  cachectic  condition. 

The  ascitic  fluid  accompanying  carcinoma  of  the  body  and  obtained 
by  aspiration  contains  sometimes  large  round  or  pear-shaped  endo- 
thelial  cells  with  large  nuclei,  either  isolated  or  in  groups.  This  sign 
is  of  some  positive  value,  but  not  of  negative — i.  e.  if  these  malig- 
nant cells  and  cell-groups  are  found,  it  is  very  likely  that  the  disease 
is  malignant  (carcinoma,  sarcoma,  or  papilloma),  but  their  absence 
does  not  prove  anything.1 

Prognosis. — The  disease  is  fatal.  Even  the  most  radical  treatment 
effects  only  quite  exceptionally  a  permanent  cure,  and  it  is  even 
doubtful  if,  upon  the  whole,  it  prolongs  life.  Under  palliative  treat- 
ment patients  affected  with  carcinoma  of  the  cervix  may  live  three  or 
four  years.  When  the  disease  is  in  the  corpus  they  live  rarely  more 
than  one  or  two. 

Treatment. — Prophylaxis. — Cervix  lacerations,  if  they  give  rise  to 
eversion  and  consequent  irritation  of  the  mucous  membrane,  should 
be  operated  on  (p.  399),  and  endometritis  treated  as  stated  above 
(pp.  413,  414). 

Coe2  recommends  the  excision  of  the  cervix  in  cases  of  extensive 
erosion  with  general  induration,  whether  cancer  has  actually  developed 
or  not.  He  cuts  out  a  cone,  the  apex  of  which  may  be  as  high  as  the 
os  internum,  the  mucous  membrane  of  the  entire  canal  being  removed 
with  the  cone,  but  leaves  the  vaginal  mucous  membrane.  He  then 
introduces  a  plug  of  glass  or  iodoform  gauze,  and  closes  the  cervix 
with  deep  silver-wire  sutures. 

Palliative  Treatment. — By  far  the  greater  number  of  patients  do 
not  come  under  observation  before  the  disease  has  spread  so  much 
that  a  radical  treatment,  aiming  at  the  complete  removal  of  the 
affected  part,  cannot  be  instituted  with  any  hope  of  benefiting  the 
patient.  But  very  much  may  be  clone  to  relieve  her,  prolong  her 
life,  and  make  her  a  less  objectionable  companion  for  others.  The 
chief  indications  are  to  relieve  pain,  combat  hemorrhage  and  bad 
odor,  and  keep  up  the  patient's  strength. 

The  disease  being  fatal,  and  having  only  a  duration  of  a  few  years, 
we  need  not  be  afraid  of  making  opium-eaters  of  our  patients 
(p.  226).  There  are  no  other  drugs  that  will  relieve  the  pain  of 
cancer  as  opiates  do,  and  the  patient  should  simply  have  as  much  of 
them  as  is  needed  to  make  her  comfortable.  In  cancer  of  the  cervix 
small  doses  will  suffice  for  a  long  time,  and  need  only  be  increased 

1  For  details  see  Garrigues'  Diagnosis  of  Ovarian  Cyst.  pp.  94-97. 

2  H.  C.  Coe,  Med.  News,  Feb.  16,  1889. 
33 


514  DISEASES  OF  WOMEN. 

very  gradually.  In  the  beginning  four  drops  of  Magendie's  solu- 
tion, two  or  three  times  a  day,  are  enough,  and  I  have  not  found  it 
necessary  to  go  beyond  ten  or  twelve  drops  three  or  four  times  a 
day  in  the  later  stages.  The  hypodermic  injection  is  most  efficaci- 
ous, but  for  obvious  reasons  most  patients  take  their  morphine  by 
the  mouth.  In  cancer  of  the  body  larger  doses  are  required  to  dull 
the  pain. 

Moderate  hemorrhage  may  be  kept  in  check  by  means  of  injections 
with  chloride  of  iron  (p.  172).  In  more  profuse  hemorrhage,  or  if 
the  seat  is  in  the  body,  curetting  (p.  176)  is  of  great  value.  In 
removing  large  sprouting  masses  from  the  cervix  I  have  found 
Thomas's  spoon-saw  (p.  478)  a  very  useful  instrument.  The  patient 
is  placed  in  the  dorsal  or  left-side  position,  Garrigues'  weight-speculum 
or  a  Sims  speculum  is  introduced,  the  tumor  is  seized  with  a  volsella, 
and  as  much  of  the  friable  tissue  as  possible  is  removed  with  the 
spoon-saw,  followed  by  Simon's  sharp  spoon.  Jagged  edges  may  be 
cut  off  with  curved  scissors.  Most  operators  use  the  thermo-  or  gal- 
vano-cautery  as  supplemental  to  curetting  in  order  to  arrest  hemor- 
rhage and  destroy  infiltrated  tissue.  Others  object  to  the  cautery, 
because  it  destroys  the  tissue  that  is  not  yet  affected,  and  thus  hastens 
the  process  of  destruction.  Whether  the  cautery  be  used  or  not,  the 
cervix  is  packed  with  pledgets  wrung  out  of  a  solution  of  chloride  of 
iron  (p.  179),  and  the  vagina  with  an  antiseptic  plug  (p.  179). 

After  having  removed  this  tampon  the  next  day,  some  apply  pled- 
gets wrung  out  of  a  solution  of  chloride  of  zinc  (^v  to  distilled  water 
3j,  or,  if  there  is  a  wall  more  than  a  quarter  of  an  inch  thick  around 
the  cancerous  tissue,  even  equal  parts).  The  vagina  is  protected  by  a 
tampon  of  cotton  balls  wrung  out  of  a  solution  of  bicarbonate  of 
soda  (1  part  to  2  of  water),  which  is  left  in  for  two  or  three  days. 
If  the  zinc  pledgets  do  not  come  off  easily,  they  are  left  for  a  day  or 
two  longer.  This  treatment  produces  a  thick  slough,  leaving  a  vel- 
vety surface,  and  is  followed  by  considerable  contraction.  It  may 
even  effect  a  permanent  cure,  but  is  not  quite  safe,  since  the  action  of 
the  caustic  may  involve  healthy  tissue  or  the  cancerous  degeneration 
go  deeper  than  anticipated. 

Some  substitute  excision  with  knife  and  scissors  for  curetting  as  the 
first  step  in  the  chloride-of-zinc  treatment,  cutting  out  a  cone  from 
the  vaginal  junction  to  the  internal  os.  During  the  separation  of  the 
slough  and  cicatrization  disinfectant  injections  are  used. 

Nobody  should  undertake  curetting  for  a  large  cancerous  mass 
without  being  prepared  to  ligate  the  uterine  artery  from  the  vagina 
(p.  182),  or  even  to  extirpate  the  uterus  if  necessary.1 

1  I  did  so  in  a  case  in  which  I  had  refused  to  perform  the  radical  operation  on 
account  of  infiltration  of  the  broad  ligament  on  one  side.  The  curetting  entailed  a 
large  opening  in  Douglas's  pouch.  I  then  performed  vaginal  hysterectomy.  The 


DISEASES  OF  THE   UTERUS.  515 

It  is  also  recommended  to  scrape  off  all  diseased  tissue  and  dress 
the  wound  with  a  saturated  solution  of  soda. 

Hemostatic  drugs  are  not  of  much  avail.  Gossypium  (p.  227), 
however,  is  useful  as  an  adjuvant. 

Injections  with  creolin  (p.  173)  are  very  valuable,  both  as  a  hemo- 
static  and  an  antiseptic.  The  odor  of  the  drug  itself  is  by  no  means 
disagreeable.  Still  more  astringent  is  liqu.  ferr.  chloridi  (p.  172). 
Permanganate  of  potassium  (enough  to  give  the  water  a  dark  purple 
color)  has  no  odor  at  all,  but  stains  the  linen. .  Peroxide  of  hydrogen 
has  neither  odor  nor  color,  and  has  a  high  disinfecting  power.  Small 
tampons  dipped  in  terebene  and  olive  oil,  equal  parts,  may  be  left  in 
place  for  two  or  three  days.  Equal  parts  of  iodoform  and  charcoal 
applied  as  a  powder  on  the  ulcer  relieves  pain,  cleanses  the  ulcer,  and 
combats  the  odor,  but  has  a  smell  of  its  own  that  to  many  persons  is 
objectionable.  All  these  benefits  may  also  be  derived  from  the  daily 
application  of  the  odorless  aristol.  Suppositories  with  chloral  and 
tannin  (da  gr.  xv— 5ss)  combat  hemorrhage,  pain,  and  odor. 

Occasionally  the  use  of  a  styptic  tampon  (p.  179)  may  become 
necessary. 

For  carcinoma  of  the  body  Vulliet's  dilatation  (p.  156),  followed 
by  curetting  and  chloride  of  zinc,  may  be  used.  Simple  curetting, 
although  less  exact  and  powerful,  is  also  very  useful ;  repeated 
every  three  to  six  months,  it  prolongs  life  considerably. 

In  using  tonics  the  reader  should  remember  the  warning  (p.  228) 
against  giving  iron  when  there  is  any  hemorrhage. 

So  far,  no  drug  has  been  found  that  will  cure  cancer,  although  from 
time  to  time  some  new  specific  is  praised  even  by  good  observers. 
Some  years  ago  it  was  condurango-bark ;  then  came  Chian  turpen- 
tine ;  next  methyl  blue  enjoyed  a  short-lived  celebrity.  I  have  not 
seen  any  effect  from  the  use  of  these  substances ;  but  since  others  have 
claimed  success,  and  since  we  must  sometimes  prescribe  something,  I 
add  the  following  formulae : 

fy.  Extr.  condurango,  fl.  §ss ; 

Aqu.,  ad  Sviij. — M. 

Sig.  A  tablespoonful  four  times  a  day. 

1^.  Extr.  condurango,  Iss; 

Vaselini,  §iss. — M. 

Sig.  To  be  applied  daily  on  tampons  to  the  ulcerated  surface. 
1^.  Terebinthinse  Chiensis,  3ss: 

Sulphuris  sublimati,  siiss ; 

Had.  glycyrrhizse,  q.  s. 

Ft.  pil.   No.  c. 
Sig.  Three  pills  every  four  hours. 

patient  made  an  excellent  primary  recovery,  but   the  cancer,  of  course,  continued 
-developing. 


516  DISEASES  OF  WOMEN. 

To  those  who  cannot  swallow  pills  it  may  be  given  as  an  emulsion 
with  mucilage,  a  yolk  of  an  egg,  syrup,  and  sherry  wine. 

Methyl  blue  is  given  in  doses  of  3  to  4  grains,  once  or  twice  a  day, 
in  capsules,  by  the  mouth,  or  by  the  rectum.  It  is  also  injected  into 
the  tumor  (fllxx  to  3)  of  a  solution  of  1  part  to  300  parts  of  water), 
or  the  ulcer  is  covered  with  it  in  substance.  As  it  stains  every- 
thing, it  is  a  disagreeable  stuff  to  handle  and  to  take. 

Injections  of  one-eighth  of  a  grain  of  bichloride  of  mercury  into 
the  tissue  retard  the  extension  of  the  disease  and  clean  ulcers,  prob- 
ably by  obliterating  lymph-vessels  and  killing  some  microbe  : 

1^.  Hydrarg.  chloridi  corros.,       gr.  iij  ; 
Sodii  chloridi,  3j ; 

Aq.  destill.,  3j. 

M.  S. — 20  minims  for  parenchymatous  injection,  three  times  a 
week.1 

Radical  Treatment. — Although  some  of  the  heretofore-mentioned 
methods  have  been  claimed  to  have  effected  a  complete  and  perma- 
nent cure  of  cancer,  we  restrict  the  term  "  radical "  to  methods  in 
which  a  cure  is  sought  by  surgical  operations  in  the  healthy  tissue 
surrounding  the  diseased  part.  In  this  connection  we  have  to  con- 
sider the  supravaginal  amputation  of  the  cervix,  and  total  extirpa- 
tion of  the  uterus. 

The  high  cervix  amputation  (Schroeder's  method)  has  been  described 
on  p.  428.  It  is  not  an  easy  operation,  exposes  to  the  danger  of  con- 
siderable hemorrhage,  and  is  less  rational  than  the  total  extirpation 
of  the  uterus,  since  we  have  seen  that  cervical  carcinoma  often  is 
combined  with  a  beginning  of  the  same  disease  in  the  body  of  the 
womb. 

The  whole  cervix  has  also  been  cut  out  with  the  thermo-cautery,  by 
which  means  hemorrhage  is  avoided,  but  neighboring  organs  may  be 
implicated. 

Thermal  galvano-cauterization  seems  to  have  given  better  results, 
both  in  regard  to  mortality  and  the  length  of  time  before  a  relapse  oc- 
curred, than  any  other  method.2  It  is  performed  with  the  cautery 
loop,  the  cautery  knife,  and  the  dome-shaped  burner  (p.  235).  At 
least  the  whole  cervix  should  be  removed.  If  the  uterus  is  immo- 
bile, the  supravaginal  amputation  is  made  with  the  cautery  knife,  not 
the  loop  (Fig.  276),  and  thorough  cauterization  of  the  bottom,  sides, 
and  edges  of  the  excavation  is  added.3 

The  need  of  a  costly  instrumentarium  and  its  liability  to  get  out 

1  Schramm,  Centralbl.  f.  Gyndk.,  1888,  vol.  xii.  p.  213. 

2  Statistics  of  a  large  personal  experience  have  been  published  by  Pawlik  of  Vienna 
and  John  Byrne  of  Brooklyn,  N.  Y.,  Gynecol.  Trails.,  1889,  vol.  xiv.  p.  90.  Dr.  Byrne's 
battery  and  instruments  may  be  obtained  from  Mr.  Kaysan,  34  Bond  St.,  Brooklyn. 

3  John  Byrne,  Amer.  Jour.  Obst.,  Oct.,  1895,  vol.  xxxii.  p.  559. 


DISEASES  OF  THE    UTERUS. 


517 


FIG.  276. 


of  order  have  undoubtedly  prevented   this  method  from  becoming 
more  popular. 

The  total  extirpation,  or  hysterectomy,  may  be  performed  by  the 
vaginal,  abdominal,  vagino-abdominal,  sacral, 
perineal,  or  perineo-vaginal  section. 

Vaginal  hysterectomy  is  a  German  operation 
that  has  met  with  much  opposition  in  this 
country.1 

The  bad  results  are,  however,  probably  due, 
in  a  great  measure,  to  the  fact  that  it  has  been 
undertaken  when  the  disease  had  progressed  too 
far.  It  is  contraindicated  if  the  carcinoma  is 
not  strictly  confined  to  the  uterus  proper.  The 
uterus  should  be  freely  movable,  and  an  exam- 
ination under  anesthesia  should  not  reveal  any 
infiltration  of  the  broad  ligaments  or  of  the 
pelvic  glands.  But  even  with  these  restrictions 
relapses,  as  a  rule,  come  sooner  or  later,  the 
probable  explanation  being  that  at  the  time  of 
the  operation  there  is  already  an  infiltration  of 
the  surrounding  parts  which  cannot  be  felt.  A.  Martin  has,  how- 
ever, tried  to  prove  by  statistics  that  the  permanent — or  rather  final 
— results  are  as  good  after  extirpation  of  the  cancerous  uterus  as  in 
operation  for  cancer  in  any  other  part  of  the  body. 

Modus  Operandi. — The  operation  may  be  performed  with  ligatures, 
pressure-forceps,  thermo-cautery,  or  galvano-cautery.      In  order  to 

FIG.  277. 


knif. 


Supravaginal  Amputation 
of  Cervix  with  the  gal- 
vano-caustic  knife. 


Bernays'  Utero-tractor. 

avoid  infection  of  the  wound  from  the  cervix  or  the  interior  of  the 
wound  the  latter  should  be  cleaned  with  a  disinfectant  injection  and 
the  former  cauterized. 

The  ligatures  and  forceps  may  be  used  as  described  for  the  removal  of 
the  fibroid  uterus  (pp.  483-488).    As  the  cervix  usually  is  most  affected 

1  J.  Byrne,  Gyn.  Trans.,  1889,  vol.  xiv.  p.  90;  ibid.,  1892,  vol.  xvii.  p.  3;  Baker, 
ibid.,  1891,  vol.  xvi.  p.  170;  Keamy.  Oyn.  Trans.,  1888,  vol.  xiii.  p.  183;  Jackson, 
Med.  News,  Jan.  18,  1890;  Coe,  Amer.  Jour.  Obst.,  June,  1890,  vol.  xxiii.  p.  587. 


518  DISEASES  OF   WOMEN. 

and  offers  a  bad  hold  for  the  traction-forceps,  some  instrument  is 
needed  that  can  take  hold  of  the  uterus  from  within.  For  this  pur- 
pose Bernays'  utero-tractor  (Fig.  277),  with  its  series  of  thick  lateral 
projections,  has  proved  very  satisfactory  in  my  hands.  It  is  intro- 
duced closed  into  the  cavity  of  the  body  of  the  uterus,  opened,  and 
traction  made  with  it,  in  order  to  make  the  hooks  penetrate  the  flesh. 

The  use  of  pressure-forceps  instead  of  ligatures  is  often  necessary 
on  account  of  lack  of  space,  and  is  by  many  preferred  under  all  cir- 
cumstances.1 

In  order  to  avoid  inoculation  of  cut  surfaces  with  cancer  germs, 
hysterectomy  for  carcinoma  of  the  uterus  is  of  late  often  done  with 
pressure-forceps  and  the  thermo-cautery — so  called  thermo-cauter- 
ectomy  of  the  uterus.  First,  the  cancerous  surface  is  cauterized  with 
Paquelin's  instrument  and  the  vagina  disinfected.  Next,  a  trans- 
verse incision  is  made  with  the  cautery  just  below  the  bladder,  the 
latter  separated  from  the  uterus  with  blunt  instruments  and  fingers, 
and  the  wound  cleaned  with  a  strong  solution  of  corrosive  sublimate 
before  the  peritoneum  of  the  vesico- uterine  pouch  is  severed.  Next, 
the  posterior  fornix  of  the  vagina  is  opened  with  the  thermo-cautery, 
and  the  mucous  membrane  of  the  lateral  fornix  incised  with  the  same. 
Pressure-forceps  are  placed  on  the  parametria  and  broad  ligaments  as 
described  above,  and  the  uterus  cut  loose  with  the  thermo-cautery.2 

Still  better  than  the  thermo-cautery  is  the  galvano-cautery.  This 
instrument  gives  off  much  less  radiating  heat,  so  that  the  neighboring 
parts  are  not  so  easily  injured,  and,  on  the  other  hand,  it  seems  to  exert 
a  remedial  influence  on  the  tissue  even  at  some  distance.  It  is  claimed 
that  this  method  not  only  is  characterized  by  absence  of  fever  and 
pain,  but  that  the  scar  shows  a  particular  immunity  from  reappear- 
ance of  the  disease,  and  that  there  is  an  unusually  long  period  of 
exemption  before  the  disease  reappears  in  remote  organs.3 

Mackenrodt  goes  so  far  as  to  demand  the  extirpation  of  the  upper 
half  or  the  whole  of  the  vagina  in  all  cases  in  which  the  uterus  is 
being  removed  on  account  of  carcinoma.  The  reason  is  that  there  is 
great  suspicion  of  the  vagina  being  in  a  state  of  latent  infection,  and 
there  is  no  means  of  distinguishing  a  healthy  vagina  from  one  thus 
affected.  He  uses  the  galvano-cautery.  He  begins  the  operation  with  a 
lateral  incision  with  the  cautery-knife  through  the  left  vaginal  wall  and 
the  perineum.  Next,  he  seizes  the  edge  of  this  incision  with  a  forceps 

1  I  do  not  know  if  it  is  more  than  an  accident  that  I  lost  a  patient  by  tetanus  who 
had  been  doing  excellently  until  the  ninth  day  after  the  extirpation  by  the  clamp 
method.     Still,  it  has  been  surmised  that  similar  occurrences  after  ovariotomy  and 
the  extraperitoneal  treatment  of  the  pedicle  after  abdominal  hysterectomy  for  fibroids 
stood  in  some  relation  to  the  use  of  clamps  and  pins.     The  forceps  has  also  caused 
the  formation  of  a  fecal  fistula. 

2  Cenlralbl.  f.  Oynak.,  1895,  No.  21,  vol.  xix.  p.  560. 

3  John  Byrne,  Amer.  Jour.  Obst.,  Oct.,  1895,  vol.  xxxii.  pp.  565,  566. 


DISEASES  OF  THE   UTERUS.  519 

and  dissects  it  off  with  the  cautery  up  to  the  vaginal  portion,  rolls  the 
vagina  around  the  forceps,  and  burns  it  loose  from  the  vaginal  por- 
tion, proceeding  first  toward  the  rectum,  then  to  the  right  side,  then 
to  the  bladder,  and  finally  back  to  the  starting-line. 

If  only  the  upper  half  of  the  vagina  is  to  be  removed,  a  circular 
incision  is  made  with  the  cautery  between  the  upper  and  lower  half 
through  the  whole  thickness  of  the  vagina,  and  then  the  upper  half 
is  removed  as  described  above.1 

This  method  may,  perhaps,  be  of  value  in  preventing  relapse,  but 
it  must  entail  a  tedious  convalescence,  and  lead  to  atresia  or  consider- 
able stenosis  of  the  genital  tract,  and  can,  therefore,  not  be  followed 
if  the  vagina  is  yet  needed  as  an  organ  of  copulation. 

The  pelvis  and  vagina  are  packed  as  described  above  (p.  486). 
The  pregnant  cancerous  uterus  has  repeatedly  been  successfully  re- 
moved in  the  second  and  third  month  by  vaginal  hysterectomy,  which 
is  particularly  indicated  under  these  circumstances. 

An  accident  that  is  not  very  rare  in  separating  the  bladder  from  the 
uterus  is  the  formation  of  a  vesicovaginal  fistula.  If  such  a  thing 
happens,  the  opening  in  the  bladder  should  be  closed  at  the  end  of  the 
operation,  and  all  precautions  taken  to  insure  healing  (pp.  367,  369). 
If  the  attempt  fails,  and  spontaneous  closure  does  not  occur,  and  there 
is  no  relapse,  the  fistula  should  be  closed  later. 

In  order  to  gain  room  for  the  extirpation  of  the  uterus,  the  peri- 
neum and  the  whole  rectovaginal  septum  has  been  cut  through  in  the 
median  line,  and  healing  by  first  intention  has  been  obtained  by 
means  of  silkworm-gut  sutures  (Winckel). 

Sacral  Hysterectomy. — 1.  Kraske's  Method. — Kraske's  operation  for 
cancer  of  the  rectum  has  been  adapted  to  the  removal  of  the  cancer- 
ous uterus.  The  patient  is  placed  in  Sims's  position.  A  curved 
incision  is  made  from  the  iliosacral  synchondrosis  on  the  right  side 
to  the  tip  of  the  coccyx.  Then  the  gluteus  maximus  muscle  and  the 
great  and  lesser  sacrosciatic  ligaments  are  detached  from  the  sacrum. 
The  coccyx  is  freed  all  around,  and  removed,  together  with  the  lower 
end  of  the  sacrum,  by  sawing  the  latter  bone  through  from  between 
the  third  and  fourth  posterior  sacral  foramina  on  the  right  side  to 
the  left  cornu.  The  rectum  is  loosened  and  pushed  over  to  the  left 
side.  The  peritoneum  is  incised  close  to  the  margin  of  the  rectum, 
exposing  the  posterior  surface  of  the  uterus.  The  ligaments  may  now 
be  tied  and  severed,  and  the  uterus  separated  from  the  bladder. 

This  operation  is  recommended  in  cases  in  which  the  uterus  is  large 
and  the  body  of  the  organ  fills  up  the  pelvis,  or  in  which  the  ova- 
ries and  tubes  are  the  seat  of  prior  disease  and  are  adherent.2  The 

1  Mackenrodt,  Ceniralhlf.  Gyuak.,  1896,  vol.  xx.  No.  5,  p.  129. 

2  Details  may  be  found  in  a  paper  by  E.  E.  Montgomery  of  Philadelphia  in  The 
Trans,  of  the  Amer.  Assoc.  of  Obstetricians  and  Gynecologists,  1891. 


520  DISEASES  OF  WOMEN. 

mortality  is  very  great,  and  the  wound  heals  very  slowly,  and  is  apt 
to  leave  fistulae. 

2.  Hegar's  Method. — Hegar  makes  on  the  posterior  surface  of  the 
sacrum  a  V-shaped  incision  with  the  base  turned  upward,  cuts  muscles 
and  ligaments  on  the  edges  of  the  bone,  detaches  the  rectum,  and  cuts 
the  sacrum  with  a  chain-saw  between  the  third  and  fourth  sacral 
foramina  in  a  slanting  line,  preserving  the  periosteum  on  the  posterior 
side.  The  end  of  the  sacrum  is  not  detached,  but  only  thrown 
upward,  and  later  replaced. 

In  regard  to  the  whole  procedure  of  sacral  hysterectomy  it  may  be 
said  that  a  cancerous  uterus  that  cannot  be  removed  by  the  vagina  is 
not  fit  for  extirpation. 

Perineal  Hysterectomy  (Zuckerkandl's  Method)  opens  the  way  to  the 
uterus  by  a  transverse  perineal  incision  from  one  tuberosity  of  the 
ischium  to  the  other,  and  by  separating  the  vagina  from  the  rectum. 

Abdominal  Hysterectomy  (Freund's  Method)  for  carcinoma  was  at 
first  attended  with  such  extreme  mortality  that  the  operation  was  uni- 
versally abandoned,  and  was  only  used  as  a  necessary  addition  to 
vaginal  hysterectomy  (vagino-abdominal  hysterectomy)  when  difficul- 
ties were  encountered  which  could  not  be  overcome  in  any  other  way. 
Still,  by  the  easy  access  it  gives  to  all  the  pelvic  organs  it  is  prefer- 
able to  the  sacral  and  the  perineal  methods.  jAnd  the  great  success 
obtained  with  abdominal  hysterectomy  for  fibroids  of  the  uterus  has 
brought  some  operators  back  to  abdominal  hysterectomy  for  cancer 
also.  It  offers  the  advantage  that  one  can  remove  more  of  the  broad 
ligaments,  and  thus  come  farther  away  from  the  seat  of  the  disease. 
By  previous  introduction  of  flexible  catheters  into  the  ureters  by 
Kelly's  method  (p.  163)  these  organs  may  be  avoided. 

Perineo-vaginal  Hysterectomy  (KchuchardCs  Method).1 — The  same 
advantages  are,  however,  claimed  for  the  peri neo- vaginal  method, 
which  is  particularly  adapted  to  cases  in  which  one  of  the  broad 
ligaments  is  involved  in  the  cancerous  degeneration.  The  patient  is 
placed  in  the  dorsal  position  with  drawn-up  feet.  On  that  side  on 
which  the  ligament  is  affected  an  incision  is  made  from  a  point  be- 
tween the  middle  and  posterior  third  of  the  labium  majus,  encircling 
the  anus  at  the  distance  of  two  finger-breadths,  and  ending  about  the 
level  of  the  tip  of  the  coccyx.  This  incision  is  deepened,  especially 
in  its  anterior  part,  in  the  adipose  tissue  of  the  ischio-rectal  fossa, 
until  the  wall  of  the  vagina  is  exposed.  Next,  the  whole  vaginal 
wall  is  split  from  below  up  to  the  cervix,  and  after  that  the  operation 
is  the  same  as  in  common  vaginal  hysterectomy  with  ligatures — cir- 
cular incision  around  the  cervix,  opening  of  the  pouch  of  Douglas, 
severance  of  the  ligaments,  separation  of  the  bladder  from  the  uterus, 
only  with  this  difference,  as  it  is  claimed,  that  everything  is  done 
1  Centrcdbl.f.  Chirurgie,  1894,  No.  30,  Beilage,  p.  61. 


DISEASES  OF  THE   UTERUS.  521 

with  the  greatest  ease,  and  that  all  ligations  are  made  under  the 
guidance  of  the  eye.  Both  ureters  can  be  extensively  laid  free,  and 
even  diseased  parts  of  the  bladder  may  be  cut  out.  The  incisions 
are  only  made  on  one  side,  and  the  wound  heals  by  granulation  in 
three  weeks. 

If  the  uterus  is  movable  and  any  part  of  it  is  cancerous,  the  whole 
organ,  in  my  opinion,  should  be  removed,  together  with  the  append- 
ages. If  it  is  immobile,  a  suitable  palliative  treatment  up  to  extir- 
pation of  the  cervix  is  indicated. 

In  order  to  be  able  to  extirpate  cancerous  glands  from  the  pelvic 
floor  it  has  been  advised  to  ligate  the  anterior  division  of  the  internal 
iliac  artery,  which  normally  gives  off  the  superior  vesical,  the  vaginal, 
the  uterine,  the  obturator,  the  middle  hemorrhoidal,  the  internal 
pudic,  and  the  sciatic  arteries,  and  by  the  ligation  of  which  the  sur- 
geon would  be  enabled  to  work  in  a  bloodless  field.  But  the  internal 
iliac  artery  and  its  branches  are  subject  to  many  variations.  Frequently 
there  is  no  separation  into  an  anterior  and  a  posterior  division,  or  the 
anterior  division  may  be  so  short  that  it  cannot  be  ligated.  It  would, 
therefore,  be  necessary  to  tie  the  whole  trunk  of  the  internal  iliac, 
which  can  be  done.  It  lies  between  the  upper  end  of  the  sacrum  and 
the  upper  end  of  the  great  sacro-sciatic  notch,  and  is  usually  an  inch 
to  an  inch  and  a  half  in  length,  but  sometimes  it  is  only  half  an  inch 
long.1  It  lies  at  the  inside  of  the  psoas  muscle,  under  the  peritoneum. 
The  vein  lies  behind  it  and  somewhat  to  its  inner  side,  the  ureter  in 
front  and  to  the  outer  side  (Fig.  83,  p.  82). 

The  obturator  artery  is  especially  erratic,  not  unfrequently  arising 
from  the  posterior  division  of  the  internal  iliac,  and  sometimes  from 
the  external  iliac  or  the  epigastric,  which  is  of  so  much  more  import- 
ance as  the  obturator  gland  is  more  liable  to  be  affected  than  any 
other.  But  when  once  glands  are  affected  there  is  no  telling  how  far 
the  infiltration  extends,  and  under  such  circumstances  it  is  better  to 
desist  from  operation. 

F.  Papilloma.    ' 

Under  the  name  of  papilloma  many  different  tumors  have  been 
described  which  have  in  common  a  dendritic,  digitate,  or  villous 
shape.  Most  of  them  are  simply  a  form  of  carcinoma  of  the  cervical 
portion — Clarke's  cauliflower  excrescence  (see  p.  508).  Others  are 
fibroid  polypi  (p.  470),  formed  by  increase  in  size  of  the  papillae  of 
the  cervix,  and  are  generally  covered  with  stratified  flat  epithelium. 
They  have  a  pedicle  composed  of  connective  tissue  and  muscular  fibers. 
Others,  again,  contain  glands,  and  belong,  therefore,  to  the  mucous 
polypi  (p.  408).  Others,  again,  are  sarcomas  that  have  taken  the 
papillomatous  form  (p.  504). 

1  "  Quain's  Anatomy,"  9th  ed.,  1882,  vol.  i.  p.  451. 


522  DISEASES  OF  WOMEN. 

Some,  finally,  are  true  papittomas.  In  these  the  tumor  is  formed 
by  hypertrophy  of  the  papillae  of  the  vaginal  portion.  It  contains 
highly  dilated  capillaries  and  larger  vessels  with  very  thin  walls,  but 
no  epithelial  elements.  It  gives  rise  to  a  profuse  watery  discharge 
and  hemorrhage,  but  the  general  health  does  not  suffer  much,  and  if 
the  growth  is  removed  by  an  operation  in  the  healthy  tissue,  no 
relapse  follows.  But  when  these  tumors  become  old,  epithelial  ele- 
ments appear  in  them,  and  they  take  on  the  structure  of  epithelioma. 

This  true  papilloma  is  likewise  found  springing  from  the  mucous 
membrane  of  the  body  of  the  uterus,  but  is  exceedingly  rare  in  that 
locality. 

Treatment. — True  papilloma  is  to  be  treated  by  amputation  of  the 
cervix,  or,  if  situated  in  the  cavity,  by  curetting  and  cauterization. 

G.  Enchondroma. 

Enchondroma  has  been  found  in  the  cervix,  but  is  very  rare.  It 
should  be  removed  by  amputating  the  cervix. 

H.   Tuberculosis. 

Next  to  the  tubes,  the  uterus  is  the  part  of  the  genital  tract  which 
is  most  commonly  the  seat  of  tuberculosis.  It  may  be  primary  or 
secondary,  and  the  latter  may  again  spread  from  neighboring  organs 
or  be  due  to  infection  through  the  blood.  The  disease  is  usually 
limited  to  the  mucous  membrane.  It  occurs  in  three  forms — the 
acute  miliary,  chronic  diffuse,  and  chronic  fibroid  form.  Of  these, 
the  chronic  diffuse  is  by  far  the  most  common,  and  is  characterized 
by  the  formation  of  cheesy  masses.  Tuberculosis  is  nearly  always 
limited  to  the  body  of  the  uterus ;  and,  on  the  other  hand,  in  a  con- 
siderable portion  of  the  few  cases  of  cervical  tuberculosis  on  record 
the  disease  did  not  invade  the  body.1 

Diagnosis. — Besides  offering  the  symptoms  of  endometritis,  the 
uterus  is  considerably  enlarged,  which  is  partly  due  to  tuberculous 
infiltration,  partly  to  hyperplasia  of  the  normal  elements.  Knobs 
may  be  felt  near  the  cornua.  If  the  os  is  closed,  pus  may  accumu- 
late, so  as  to  form  a  fluctuating  tumor  (pyometra,  p.  326).  If  it  is 
open,  caseous  masses  may  be  expelled  from  it.  Shreds  removed  with 
the  curette  and  examined  microscopically  may  show  bacilli  and  cells, 
as  described  on  p.  288.  As  a  rule,  a  tubercular  affection  is  at  the 
same  time  found  in  the  tubes  and  the  lungs. 

Tuberculous  ulceration  of  the  cervical  portion  may  be  mistaken  for 
carcinoma.  Microscopical  examination  of  a  piece  cut  out  from  the 

1  J.  Withridge  Williams,  "  Tuberculosis  of  the  Female  Generative  Organs,"  Johns 
Hopkins  Hospital  Report  in  Pathology,  ii.  Baltimore,  1892,  p.  126. 


DISEASES  OF  THE  UTERUS.  523 

neighboring  tissue  shows,  however,  an  entirely  different  structure  in 
the  two  diseases. 

Treatment. — As  to  general  treatment,  the  reader  is  referred  to  what 
has  been  said  in  speaking  of  tuberculosis  of  the  vulva  (p.  288).  The 
local  treatment  consists  in  curetting  and  the  application  of  iodoform. 
If  the  disease  relapses  and  the  general  condition  of  the  patient  is  not 
too  bad,  the  uterus,  together  with  the  appendages,  should  be  removed 
by  vaginal  hysterectomy. 


PART  V. 

DISEASES  OF  THE  FALLOPIAN  TUBES. 


CHAPTER  I. 

MA  INFORMATIONS. 

THE  tubes  are  sometimes  unusually  large.  In  most  cases  this 
increase  in  size  is  due  to  the  presence  of  some  abdominal  tumor,  with 
which  the  tube  is  connected  and  grows  in  length  and  width.  But 
even  apart  from  any  such  complication  it  has  been  found  to  measure 
six  inches  and  a  half  in  length.  One  tube  may  be  longer  than  the 
other. 

They  may  be  wound  in  a  spiral  or  be  abnormally  contorted,  condi- 
tions which  predispose  to  retention  of  fluid,  inflammation,  and  extra- 
uterine  pregnancy. 

There  may  be  from  one  to  three  accessory  abdominal  ostia.  They 
are  surrounded  by  fimbrise  and  situated  near  the  abdominal  end  of 
the  tube,  on  the  upper  part  of  the  wall. 

There  may  also  be  accessory  tubes,  either  as  cystic  diverticula 
starting  from  the  tube,  but  without  communication  between  the  two 
cavities,  or  as  independent  tubes  with  fimbrise  starting  from  the  meso- 
salpinx.  In  the  latter  variety  ectopic  gestation  may  take  place — 
paratubal  pregnancy.1 

The  tubes  may  be  absent,  on  one  or  both  sides,  which  is  due  to  a 
destruction  of  the  corresponding  part  of  the  Miillerian  ducts  in  the 
embryo. 

In  other  cases  there  may  be  a  partial  or  total  absence  of  tunneling 
of  the  tubes,  the  result  of  an  arrest  of  development  (p.  30).  In  others, 
again,  the  tube  is  normal  near  the  uterus,  but  is  soon  lost  in  the  con- 
nective tissue  of  the  broad  ligament.  The  corresponding  ovary  is 
usually  absent  or  little  developed. 

Deficient  development  of  the  tube  may  be  the  cause  of  pain  at  the 
menstrual  period,  and  local  peritonitis,  when  ovula  and  blood  from 
the  Graafian  follicles  fall  into  the  abdominal  cavity. 

At  the  fimbriated  end  of  the  tube  is  often  found  a  little  cyst  called 
the  hydatid  of  Morgagni.  Its  inside  has  a  ciliated  epithelium,  and  it  is 
filled  with  a  clear  fluid.  As  a  rule,  it  has  only  the  size  of  a  pea,  but 
it  may  acquire  that  of  an  English  walnut.  It  is  not  of  surgical 
interest. 

1  Sanger,  Monatsschr.  f.  GeburtshiUfe  und  Gynakologie,  1895,  vol.  i.  No.  1,  p.  25. 
524 


DISEASES  OF  THE  FALLOPIAN  TUBES.  525 

CHAPTER  II. 

SALPINGITIS. 

SALPINGITIS  is  the  inflammation  of  the  Fallopian  tubes. 
Different  Forms. — It  may  be  acute  catarrhal  or  acute  purulent,  both 
of  which  are  seated  in  the  mucous  membrane,  and  are,  therefore, 
called  endosalpingitis  ;  or  it  may  be  chronic  interstitial,  which  is  also 
called  pachy  salpingitis,  mural  salpingitis,  or  parenchymatous  salpin- 
gitis, and  is  located  in  the  muscular  coat.  Salpingitis  may  be  cystic, 
and  according  to  the  character  of  the  fluid  contained  in  the  dilated 
tube  it  is  called  pyosalpinx,  which  is  filled  with  pus,  hydrosalpinx, 
which  contains  a  watery  fluid,  and  hematosalpinx,  the  contents  of 
which  are  bloody. 

Perisalpingitis  is  the  inflammation  of  the  peritoneal  covering  of 
the  tube,  a  condition  which  only  occurs  as  part  of  a  more  extended 
pelvic  peritonitis. 

Prqftuent  salpingitis  is  only  a  variety  characterized  by  the  discharge 
of  a  watery  fluid,  pus,  or  blood  from  the  tube  through  the  uterus  and 
vagina.  When  the  fluid  is  watery  the  disease  is  also  called  hydrops 
tubas  prqfluens  or  intermittent  hydrocele  of  the  ovary  (Bland  Button. 
See  Tubo-ovarian  Cysts  in  the  pathology  of  the  Ovaries.) 

Under  the  name  of  Salpingitis  isthmica  nodosa  has  been  described 
a  form  of  chronic  salpingitis  in  which  nodules  can  be  felt  at  the  cor- 
ners of  the  uterus.  In  their  interior  is  found  the  tubal  canal,  hyper- 
plasia  and  hypertrophy  of  the  muscular  elements  of  the  wall,  and 
sometimes  cysts. 

Pyosalpinx  saccata  is  a  variety  of  pyosalpiux  in  which  the  lumen 
of  the  tube  is  partitioned  off  into  a  series  of  pus-filled  sacs,  which 
partitions  may  subsequently  become  absorbed,  so  as  to  form  one 
cavity. 

Taking  the  etiology  as  base  for  a  classification,  salpingitis  may  be 
divided  into  infectious  and  non-infectious.  The  non-infectious  is 
always  catarrhal ;  the  infectious  is  nearly  always  purulent,  but  may 
in  the  beginning  or  toward  the  end  of  the  disease  be  catarrhal. 

Pathological  Anatomy. — One  or  both  tubes  may  be  diseased.  The 
infectious  form  is  usually  bilateral.  The  tube  is  swollen  to  a  thick- 
ness varying  from  that  of  a  little  finger  to  that  of  a  thumb.  In 
catarrhal  salpingitis  the  aifection  is  chiefly  limited  to  the  mucous 
membrane.  The  folds  are  edematous  and  hyperemic  or  slightly  infil- 
trated with  small  round  cells. 

The  epithelial  cells  are  swollen,  show  slight  increase  in  size  of  their 
nuclei,  and  vacuoles  form  in  their  protoplasm.  Side-branches  grow 
out  from  the  folds,  and  these,  as  well  as  the  original  folds,  may  grow 
together,  forming  closed  cavities.  The  muscular  coat  does  not 


526  DISEASES  OF   WOMEN. 

participate  much  in  the  inflammatory  process.  The  secretion  is  in- 
creased, and  contains  mucus,  albuminoids,  and  thrown- off  epithelial 
cells. 

In  purulent  salpingitis  the  process  is  more  destructive.  The  tubes 
are  swollen,  often  distorted,  adherent  to  neighboring  organs,  and 
sometimes  divided  by  internal  partitions  or  external  bands  into  a 
series  of  compartments,  which  give  them  a  beaded  appearance.  The 
epithelial  cells  lose  their  cilia.  The  epithelium  is  thrown  off  over 
large  areas,  and  the  underlying  tissue  is  crowded  with  small  round 
cells,  which  are  thrown  off  as  pus-corpuscles.  The  mucous  membrane 
is  the  primary  seat,  but  by  extension  the  inflammation  invades  the 
muscular  coat,  and  the  connective  tissue  between  the  muscle-bundles 
becomes  infiltrated  with  pus-corpuscles.  The  fimbrise  become  agglu- 
tinated to  one  another  or  to  the  ovary.  In  the  beginning  the  ostium 
uterinum  may  remain  open,  constituting  a  profluent  purulent  salpin- 
gitis. If  purulent  salpingitis  is  cured,  it  leads  to  a  temporary  or 
permanent  hypertrophy  of  the  wall  by  formation  of  new  connective 
tissue.  The  vegetations  springing  from  the  folds  grow  together,  form- 
ing a  whole  layer  of  new  formation  lining  the  original  tube. 

Interstitial  salpingitis  is  a  chronic  disease  which  has  its  seat  in  the 
muscular  coat.1  It  may  follow  either  catarrhal  or  purulent  salpin- 
gitis. The  extension  from  the  mucous  membrane  to  the  muscular 
layer  takes  place  through  the  connective  tissue.  In  the  first  stage  the 
connective  tissue  between  the  muscle-bundles  is  edematous.  Next,  a 
large  number  of  inflammatory  corpuscles  (small  round  cells)  form  in 
it,  and  even  the  smooth  muscle-fibers  themselves  break  down  and  are 
transformed  into  such  cells.  Later,  the  interstitial  inflammation  may 
lead  to  the  formation  of  new  connective  tissue.  It  is  doubtful  if 
muscular  tissue  is  also  formed.  In  this  way  the  wall  is  thickened, 
and  the  process  may  end  in  a  permanent  hypertrophy  (Fig.  278). 
On  the  other  hand,  interstitial  salpingitis  may  lead  to  atrophy  of  the 
tube.  Here  the  wall  is  thin,  the  caliber  small,  and  the  epithelium 
partially  lost.  The  muscle-tissue  is  to  some  extent  replaced  by  con- 
nective tissue. 

The  different  forms  of  salpingitis,  especially  the  purulent,  are  often 
accompanied  by  pelvic  peritonitis,  due  to  an  extension  of  the  inflam- 
mation through  the  wall  of  the  tube  to  its  peritoneal  covering,  or  to 
the  entrance  of  irritating  fluid  into  the  peritoneal  cavity  through  the 
ostium  abdominale.  In  most  cases  the  ovary  becomes  implicated  in 
the  inflammation.  It  is  full  of  small  cysts  or  may  form  an  abscess. 
An  exudation  is  formed  in  Douglas's  pouch  or  around  the  tube  and 
ovary,  which  are  then  matted  together  into  one  globular  mass.  Ad- 

1  H.  J.  Boldt  has  made  a  special  study,  illustrated  by  instructive  drawings,  of  the 
microscopical  changes  characteristic  of  this  form  in  Amer.  Jour.  Obst.,  Feb.,  1888, 
vol.  xxi.  p.  122. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  527 

FIG.  278. 


Hypertrophy  of  Fallopian  Tube  due  to  Interstitial  Salpingitis.    The  tube  is  cut  open,  showing 
the  lumen,  a,  in  the  middle  of  the  thick  hard  wall,  b.1 

FIG.  279. 


Salpingitis:  a,  tube  finger-thick  at  lower  end,  narrowed  in  many  places ;  b,  cyst  as  large  as 
a  chestnut  situated  in  the  wall  of  the  tube ;  c,  ovary  containing  a  recently  ruptured 
Graanan  follicle,  the  size  of  a  large  hazelnut;  d,  torn  adhesions.2 

1  Specimen  from  my  salpingo-oophorectomy  on  Mrs.  S.,  in  St.  Mark's  Hospital, 
on  July  24,  1890. 

2  Specimen  from  my  salpingo-oophorectomy  on  Mrs.  L.  S.,  in  St.  Mark's  Hospital, 
on  August  29,  1890. 


528 


DISEASES  OF  WOMEN. 


hesions  are  formed  to  the  intestines,  the  omen  turn,  the  bladder,  the 
uterus,  the  broad  ligament,  or  the  wall  of  the  pelvis. 

The  loss  of  epithelium  and  growth  of  new  folds  springing  from  those 
normally  formed  by  the  mucous  membrane  may  lead  to  closure  of  the 


FIG.  280. 


1.  Left  Tube  cut  open,  Catarrhal  and  Interstitial  Salpingitis :  a,  closed  fimbriae ;  a  b,  a  c, 

thickness  of  wall ;  d,  central  cavity. 

2.  Right  Tube  cut  open,  Pyosalpinx :  a,  closed  fimbriae ;  6,  cavity  filled  with  pus ;  c,  c,  c, 

smaller  cavities  communicating  with  central  canal. 

3.  Small  round  body  found  loose  in  pelvic  cavity,  probably  atrophic  right  ovary.1 

ends  of  the  tube  or  coalescence  between  the  walls  in  one  or  more 
places  in  their  course.  As  a  rule,  the  abdominal  opening  is  first 
closed  by  agglutination  between  the  fimbriae  or  between  them  and 
the  ovary.  Later,  agglutination  may  also  take  place  at  the  uterine 
end.  If  both  ends  are  closed,  the  fluid  accumulates,  forming  a  cyst, 
filled  with  a  serous,  mucous,  pultaceous,  purulent,  or  bloody  fluid. 
The  wall  is  in  most  places  thickened,  but  through  distention  or 
ulceration  in  the  interior  it  has  thin  places  liable  to  rupture.  Most 
frequently  this  thinning  is  found  in  the  upper  and  posterior  part  of 
the  tube,  so  that  the  fluid,  in  case  of  rupture  of  the  wall,  flows  into 
the  peritoneal  cavity.  In  rarer  instances  the  rupture  takes  place 
downward  between  the  folds  of  the  broad  ligament  and  produces 
pelvic  cellulitis  and  abscess. 

These  tubal  cysts  are  mostly  club-shaped,  with  a  thinner  inner  end 
and  a  thicker  outer.  Sometimes  they  are  more  pear-shaped  or  round, 
or  form  a  string  of  alternating  wide  and  narrow  parts,  like  a  string 

1  Specimen  from  my  salpingo-oophorectomy  on  Mrs.  F.  K.,  in  St.  Mark's  Hospi- 
tal, on  May  19,  1894. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  529 

of  sausages  (Fig.  279).  Different  forms  may  be  found  simultaneously 
in  the  same  individual.  Thus  I  have  seen  pyosalpinx  in  one  tube, 
the  fluid  being  purulent  with  a  few  columnar  cells,  while  the  other 
tube  showed  marked  interstitial  and  catarrhal  salpingitis,  the  much 
distended  canal  being  filled  with  a  putty-like  mass  exclusively  com- 
posed of  ciliated  columnar  epithelial  cells  (Fig.  280). 

Frequency. — Salpingitis  is  a  very  common  disease. 

Etiology. — Salpingitis  is  hardly  ever  a  primary  disease.  As  a  rule, 
it  is  secondary  to  inflammation  of  the  uterus  or  the  peritoneum.  The 
inflammation  may  follow  the  mucous  membrane  or  be  propagated  from 
the  uterus  through  the  lymphatics  of  the  broad  ligament. 

The  disease  is  nearly  always  limited  to  the  period  of  genital  activity. 
It  is  quite  frequent  in  prostitutes,  causing  colica  scortorum  ;  and  unfor- 
tunately, it  appears  often  in  newly-married  pure  women. 

Malformations,  such  as  atrophy,  a  spiral  twist,  and  angles  in  the 
course  of  the  tubes,  predispose  to  their  inflammation. 

Salpingitis  may  be  due  to  infectious  and  exanthematous  diseases, 
such  as  cholera,  typhoid  fever,  scarlet  fever,  and  smallpox.  It 
may  be  brought  on  by  flexion,  myoma  or  carcinoma  of  the  uterus, 
and  perhaps  stenosis  of  the  os,  with  retention  of  mucus  in  the  cavity, 
or  by  ovarian  disease.  It  may  be  caused  by  exposure  to  cold,  violent 
exercise  immediately  before  menstruation,  or  too  frequent  coition. 
But  in  the  large  majority  of  cases  salpingitis,  and  that  in  its  worst 
form,  the  purulent  salpingitis,  is  either  gonorrheal  or  puerperal.  If 
gonorrhea  once  invades  the  uterus,  it  has  a  great  tendency  to  spread  to 
the  tubes.  Puerperal  salpingitis  is  found  as  part  of  the  affections  cha- 
racteristic of  puerperal  infection  or  of  incomplete  abortions,  in  which 
the  ovum  or  the  spongy  decidua  is  allowed  to  remain  in  the  uterus. 

Purulent  salpingitis  may  also  be  due  to  gynecological  treatment, 
not  only  operations,  such  as  incision  of  the  cervix  ;  but  the  mere  intro- 
duction of  a  sound  or  the  administration  of  an  intra-uterine  douche 
may,  in  rare  cases,  lead  to  salpingitis  or  change  a  comparatively  harm- 
less catarrhal  into  a  purulent  inflammation. 

Symptoms. — There  is  no  pathognomonic  symptom.  Even  a  dan- 
gerous puerperal  salpingitis,  calling  for  removal  of  the  pus-filled  tubes, 
need  not  cause  any  other  symptom  than  emaciation  and  recurrent 
fever.  A  symptom,  however,  that  must  awaken  great  suspicion  is 
an  intermittent  outflow  of  mucous  or  purulent  fluid  from  the  genitals, 
but  the  same  may  sometimes  be  due  to  endometritis.  The  patient  is,  as 
a  rule,  sterile,  or  has  had  one  child,  so-called  secondary  sterility.  The 
disease  is,  in  most  cases  bilateral  or,  if  only  found  on  one  side,  the  left 
is  more  likely  to  be  affected,  a  peculiarity  which  may  have  its  cause 
in  the  preponderance  of  cervical  tears  on  this  side  (p.  396)  or  the 
absence  of  a  valve  in  the  left  ovarian  vein  (p.  74). 

Pain  may  be  insignificant  or  excruciating.    It  is  felt  in  one  or  both 

34 


530  DISEASES  OF  WOMEN. 

iliac  fossa  and  in  the  sacral  region.  It  often  has  a  colicky  character,  and 
may  be  due  to  contraction  of  the  inflamed  muscular  coat  or  to  pressure 
on  the  ends  of  nerve-filaments.  In  other  cases  the  pain  is  burning.  If 
only  one  side  is  affected,  the  pain  is  sometimes  felt  in  the  opposite  side. 
It  is  increased  by  any  kind  of  exertion,  so  that  the  woman  becomes 
unable  to  do  any  kind  of  work ;  and  it  is  much  enhanced  by  coition. 
It  is  worst  at  the  menstrual  period. 

Leucorrhea  is  common.  Often  the  patient  suffers  from  inenoivha- 
gia  or  metrorrhagia,  the  hemorrhage  taking  place  in  the  diseased 
tubes  themselves  or  in  the  uterus,  the  endometrium  of  which  may  be 
inflamed.  Periods  of  menorrhagia  may  alternate  with  others  of  amen- 
orrhea.  The  general  health  suffers,  the  patient  loses  flesh  and  strength, 
becomes  nervous,  and  often  has  fever. 

By  vaginal  examination  the  tubes  are  found  tender,  thickened, 
often  distorted  and  either  movable  or  adherent  to  neighboring  organs, 
Very  often  the  ovary  is  felt  enlarged  and  tender,  or  there  may  be  an 
exudation  or  new-formed  connective  tissue  matting  it  and  perhaps  a 
knuckle  of  intestine  and  a  part  of  the  omentum,  together  with  the 
tube,  into  one  shapeless  mass. 

A  unilateral  mass  of  this  kind  may  so  fill  the  pelvis  as  to  push  the 
uterus  over  toward  the  other  side,  at  the  same  time  canting  it  forward. 
In  case  the  masses  are  bilateral  and  large,  they  push  the  uterus  with 
the  broad  ligaments  from  behind  forward  up  against  the  anterior  wall 
of  the  pelvis,  or  press  on  it  more  from  above,  tipping  it  forward  into 
complete  anteversion.  In  other  cases  again  the  uterus  is  found  retro- 
flexed  and  often  adherent  to  the  posterior  wall  of  the  pelvis. 

Diagnosis. — The  diagnosis  of  salpingitis  may  be  very  difficult,  the  dis- 
ease being  so  often  combined  with  oophoritis,  peritonitis,  and  cellulitis. 

The  intermittent  spontaneous  outflow  of  mucus  or  pus  preceded  by 
a  burning  sensation  or  cramps  makes  the  presence  of  salpingitis  very 
probable.  This  symptom  acquires  still  more  weight  if  the  examiner 
by  gentle  pressure  exerted  on  the  tubal  region  can  make  the  fluid 
appear  at  the  os  uteri. 

Oophoralgia  is  only  found  as  a  part  of  general  hysteria ;  lumbo- 
abdominal  neuralgia  is  elicited  by  pressure  on  the  skin  over  the  iliac 
region,  but  not  by  pressure  from  the  vagina,  and  in  none  of  these 
purely  nervous  affections  is  there  any  swelling. 

From  oophoritis  the  inflamed  tube  is  distinguished  by  its  shape, 
and  sometimes  the  ovary  can  be  felt  beside  the  swollen  tube  in  a 
normal  condition,  or  only  slightly  enlarged  and  tender  compared  with 
the  swelling  formed  by  the  tube. 

Cellulitis  forms  a  swelling  situated  lower  down  than  the  swollen 
tube. 

Peritonitis  forms,  as  a  rule,  a  larger  exudation  of  more  globular 
shape  extending  from  Douglas's  pouch  to  one  of  the  iliac  fossse. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  531 

Sometimes  it  is  hard  to  tell  a  swollen  tube  from  an  intestinal  knuckle 
felt  in  Douglas's  pouch,  but  the  latter  is  not  particularly  tender,  is 
not  always  present,  and  is  sometimes  empty,  while  at  other  times 
it  contains  feces. 

In  order  to  obtain  full  knowledge  of  the  condition  of  the  tubes,  it 
is  necessary,  besides  the  common  examination  in  the  dorsal  and 
Sims's  positions  and  by  rectal  touch  (p.  142),  to  anesthetize  the  patient, 
place  her  in  lithotomy  position,  let  the  legs  fall  out,  so  as  to  put  the 
psoas  muscle  on  the  stretch,  introduce  the  fore-  and  middle  fingers  of 
one  hand  into  the  lateral  vault  of  the  vagina,  and  depress  the  ab- 
dominal wall  with  the  other.  The  vaginal  examination  is  performed 
with  the  left  hand  for  the  left  side  of  the  pelvis,  and  the  right  hand 
for  the  right  side. 

A  purulent  salpingitis  may  be  surmised  if  the  history  reveals  gon- 
orrheal  or  puerperal  infection,  and  the  purulent  nature  of  the  fluid  in 
the  tube,  together  with  the  permeability  of  the  ostium  uterinum,  is 
proved  if  pus  can  be  made  to  appear  at  the  os  uteri  by  the  above- 
mentioned  manipulation. 

Prognosis. — Salpingitis  is  a  serious  disease.  Its  course  is  usually 
a  tedious  one.  It  may  end  fatally  from  exhaustion ;  it  may  cause 
sudden  death  or  make  the  patient  an  invalid  for  life,  and  it  very  often 
entails  sterility.  It  is  especially  the  purulent  form  the  prognosis  of 
which  is  so  doubtful ;  the  catarrhal  is  more  amenable  to  treatment, 
less  protracted,  and  less  dangerous. 

Treatment. — Prophylaxis. — Women  should  be  sufficiently  clad  (see 
p.  128)  and  avoid  sudden  refrigeration  when  heated,  especially  during 
the  menstrual  period. 

As  far  as  possible  they  should  avoid  marriage  with  a  man  who  has 
or  has  had  a  gonorrhea  which  is  not  perfectly  cured  ;  or  to  put  it  the 
other  way,  a  man  with  gouorrheal  threads,  designated  with  the  Ger- 
man name  "  tripper  faden,"  in  the  urine,  or  at  whose  meatus  urina- 
rius  appears  a  little  secretion  in  the  morning,  should  not  marry  unless 
the  discharge  is  free  from  pus,  and  when  even  a  purulent  discharge, 
artificially  produced  by  injection  with  nitrate  of  silver  or  corrosive 
sublimate,  does  not  contain  gonococci  (see  latent  gonorrhea,  p.  131). 

Childbirth  should  be  surrounded  by  all  antiseptic  precautions.1  In 
cases  of  incomplete  abortion  the  uterus  should  be  emptied  immedi- 
ately. 

If  salpingitis  is  present  the  doctor  should  abstain  from  making  an 
incision  in  the  cervix,  introducing  an  infra-uterine  pessary,  using  in- 
tra-uterine  injections,  nay,  even  from  carrying  a  sound  into  the  uter- 

1  Full  information  in  this  respect  is  found  in  the  writer's  Practical  Guide  to  A  nti- 
septic  Midwifery  in  Hospitals  and  Private  Practice,  Detroit,  Mich.,  1886,  and  in  his 
articles  on  "  Puerperal  Infection  "  in  Amer.  System  of  Obstetrics,  Phila.,  1889,  vol.  ii. 
pp.  327-361,  and  in  Amer.  Text-book  of  Obstetrics,  Phila,,  1895,  pp.  708-719. 


532  DISEASES  OF   WOMEN. 

me  cavity,  as  all  these  interferences  may  give  new  impetus  to  the 
disease  or  change  a  catarrhal  salpingitis  into  a  purulent,  and  lead  to 
death. 

Curative  Treatment. — In  acute  salpingitis  we  prescribe  absolute  rest 
in  bed,  fluid  diet,  an  ice-bag  on  the  lower  part  of  the  abdomen,  opium 
suppositories  (p.  226),  hot  vaginal  douches  (p.  171),  and,  if  necessary, 
a  saline  aperient  (p.  225).  Hot  rectal  injections  serve  both  to  move 
the  bowels  and  combat  the  inflammation.  If  the  inflammation  is 
unmistakably  purulent  and  gives  rise  to  serious  symptoms,  it  is  safer 
to  remove  the  appendages  immediately  without  losing  any  time  in 
palliative  treatment. 

In  the  chronic  form  much  may  be  accomplished  by  mild  treatment 
if  the  patient  can  take  care  of  herself.  It  is  often  well,  even  in  this 
form,  to  begin  with  confining  the  patient  to  her  bed  for  three  or  four 
weeks.  Painting  internally  and  externally  with  tincture  of  iodine 
(pp.  170  and  188),  pledgets  soaked  in  ichthyol-glycerin  (p.  178),  gal- 
vanism with  one  pole  against  the  vaginal  vault  (p.  232)  or  in  the 
uterine  cavity  (p.  231),  preferably  the  former,  scarification  of  the 
cervix  (p.  186),  intra-uterine  applications  of  chloride  of  zinc  (p.  170), 
blisters  applied  over  the  inguinal  fossa,  superficial  cauterization  of 
the  same  region  with  Paquelin's  cautery,  poultices,  hot-water  bags, 
Priessnitz  compresses  (p.  187),  and  warm  entire  baths, — are  all  very 
effective  remedies,  which,  combined  with  substantial  food,  mild  stimu- 
lants (p.  224),  and  tonics  (p.  225),  may  effect  a  cure.  In  milder  cases 
of  swollen  tubes  and  ovaries,  curetting  (p.  176),  followed  by  packing 
of  the  uterine  cavity  with  iodoform  gauze  (p.  180),  has  proved  very 
beneficial  in  the  writer's  hands — an  effect  which  probably  must  be 
attributed  to  the  depletion  from  the  surroundings  due  to  the  drainage 
from  the  uterus. 

Others  think  they  can  evacuate  fluid  from  the  tube  by  dilating  the 
uterus,  curetting,  especially  around  the  openings  of  the  tubes,  and 
packing  with  iodoform  gauze,  to  be  removed  every  day  or  two. 

Massage  (p.  190)  has  also  been  praised,  but  seems  to  me  to  be  sur- 
rounded by  too  great  dangers.  The  only  indication  I  see  for  it  is  the 
cases  in  which  the  abdominal  opening  of  the  tube  is  closed,  and  the 
uterus  remains  open.  Under  such  circumstances  a  very  gentle  press- 
ure following  the  course  of  the  tube  from  without  inward  toward  the 
uterus  may  press  out  the  fluid  which  has  accumulated  in  the  tube. 
But  the  diagnosis  is  not  easy  to  make  on  the  living,  and  if  the  abdom- 
inal ostium  was  just  a  little  agglutinated,  the  pressure  might  reopen  it 
and  drive  the  contents  of  the  tube  into  the  peritoneal  cavity. 

Intra-uterine  injections  should  be  avoided,  as  they  are  apt  to  increase 
the  inflammation  of  the  tubes. 

If  these  milder  measures  do  not  succeed,  the  tube  may  be  attacked 
surgically  from  the  vagina  or  through  the  abdominal  wall. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  533 

Catheterization  of  the  tube  is  in  normal  cases,  and  in  most  patho- 
logical ones,  impossible.  It  has  only  been  performed  when  the  ute- 
rus was  lateroflexed,  and  the  ostium  internum  much  dilated.  In 
other  cases  of  supposed  catheterization  the  sound  has  perforated  the 
uterine  wall,  which  is  easily  done,  and,  as  a  rule,  has  no  bad  conse- 
quences (compare  p.  177). 

Aspiration  through  the  vaginal  vault  is  not  devoid  of  dangers,  not 
only  on  account  of  the  organs  that  may  be  wounded  with  the  needle, 
but  still  more  on  account  of  the  nature  of  the  fluid  that  after  its 
withdrawal  may  drip  into  the  peritoneal  cavity.  It  should,  therefore, 
only  be  used  if  the  swelling  is  situated  in  the  posterior  half  of  the 
pelvis,  so  low  down  that  it  is  within  easy  reach,  and  when  it  seems  so 
firmly  adherent  in  Douglas's  pouch  that  we  have  reason  to  hope  that 
no  fluid  will  escape  into  the  peritoneal  cavity.  Besides,  as  a  rule, 
aspiration  will  have  greater  value  from  a  diagnostic  standpoint  than 
from  a  curative.  It  is  most  likely  that  the  diseased  mucous  mem- 
brane of  the  tube  will  reproduce  a  similar  fluid. 

An  incision  may  be  made  from  the  vagina,  and  a  drainage-tube  of 
glass,  hard  rubber,  or  silver  introduced  and  fastened  to  the  vaginal 
vault  with  silver  wire  drawn  through  holes  in  the  vaginal  end  of  the 
tube.1  We  may  also  use  a  soft-rubber  tube  with  cross-bar,  and  long 
enough  to  protrude  from  the  vagina.  A  safety  pin  is  inserted  at  the 
lower  end,  and  iodoform  gauze  wound  round  tube  and  pin,  so  as  to 
close  the  tube  without  preventing  drainage.  This  method  should, 
however,  only  be  used  if  the  conditions  mentioned  in  speaking  of 
aspiration  are  present ;  and,  upon  the  whole,  if  the  diagnosis  is 
sure — that  is,  if  the  fluid  is  in  the  tube  and  not  in  the  peritoneal 
oavity  or  the  connective  tissue  of  the  pelvis — the  tube  should  be 
removed. 

In  all  cases  that  have  withstood  the  palliative  treatment  for  four 
months  or  longer,  an  exploratory  laparotomy  or  colpotomy  is  indicated, 
which  may  lead  to  the  removal  of  the  uterine  appendages  or  to  their 
preservation  by  different  means. 

Laparotomy,  or  abdominal  section,  is  described  under  Ovariotomy. 
Colpotomy,  or  vaginal  incision,  may  be  made  either  in  front  of  the 
cervix — anterior  colpotomy — or  behind  it — posterior  colpotomy.  The 
modus  operandi  is  exactly  the  same  as  for  the  first  steps  of  vaginal 
hysterectomy  (p.  484).  The  conservative  treatment  is  now  mostly 
carried  out  by  vaginal  section. 

Conservative  Treatment. — In  some  cases  it  suffices  to  separate  adhe- 
sions, run  a  probe  through  the  whole  length  of  the  tube,  wash  it  out 
from  the  fimbriated  end  with  a  weak  solution  of  bichloride  of  mer- 
cury (1 : 5000),  and  stitch  the  fimbrias  to  the  peritoneum  near  the 
ovary  so  as  to  prevent  them  from  curling  in  and  closing  the  abdom- 

1  T.  G.  Thomas,  Diseases  of  Women,  6th  ed.,  1891,  p.  763. 


534  DISEASES  OF  WOMEN. 

inal  opening  again.  If  the  fimbriae  cannot  be  separated,  the  end  of 
the  tube  may  be  cut  off,  and  the  raucous  membrane  stitched  to  the 
peritoneal  coat  with  a  few  catgut  sutures.  By  tying  the  rnesosalpinx 
without  comprising  the  tube  in  the  ligature,  more  or  less  of  the  latter 
may  be  removed  and  yet  a  passage  left  for  an  ovulum  from  the  ovary 
to  the  uterus.  Several  cases  of  pregnancy  under  such  circumstances 
have  been  reported.  At  the  same  time  it  may  be  necessary,  in  order 
to  prevent  reformation  of  torn  adhesions,  to  perform  abdominal  hys- 
teropexy  (p.  452)  or  shortening  of  the  round  ligaments  (p.  448).  Such 
conservative  measures  have  even  been  successful  when  the  tube  con- 
tained from  a  half  to  a  whole  fluid  rachm  of  pus.  Where  there  is  a 
large  collection  of  fluid  the  tubes  should  be  removed.' 

Salpingo-oophorectomy. — Indications. — In  acute  salpingitis  the  re- 
moval is  contraindicated  except  when  a  purulent  salpingitis  extends 
to  the  peritoneum  and  threatens  to  become  generalized.  Under  such 
circumstances  the  extirpation  should  be  performed  immediately,  with- 
out losing  time  with  palliative  measures.  If  at  the  same  time  there 
is  a  purulent  discharge  from  the  uterus,  this  organ  ought  to  be  cu- 
retted or  removed. 

The  removal  of  the  appendages  is  also  indicated  for  interstitial  sal- 
pingitis, if  the  patient  suffers  much  pain  and  has  repeated  attacks  of 
pelvic  peritonitis,  and  for  most  cases  of  cystic  salpingitis,  especially 
pyo-  and  hematosalpinx. 

It  is  true,  numerous  autopsies  have  proved  that  pus  can  become  in- 
spissated in  the  tubes  to  a  puttylike  mass,  and,  on  the  other  hand,  it 
can  probably,  by  a  process  of  clarification,  be  changed  into  a  serous 
or  mucous  fluid,  but  such  favorable  events  are  too  uncertain,  and  it 
is,  therefore,  safer  to  remove  the  tube  if  it  contains  more  than  a  very 
small  amount  of  pus. 

If  the  endometrium  shows  signs  of  infection,  it  is  advisable  first 
to  curet  and  drain  (p.  179)  before  performing  salpingo-oophorectomy, 
and  in  this  way  the  latter  operation  may  sometimes  be  avoided. 

On  the  other  hand,  in  general,  the  removal  should  not  be  under- 
taken as  long  as  the  uterine  ostium  remains  open. 

Under  all  circumstances  the  consent  of  the  patient  must  be 
obtained.  The  off-hand  way  in  which  some  operators  spay  a 
woman  without  her  knowing  it  is  not  only  unjustifiable  on  moral 
grounds,  but  exposes  the  operator  to  a  suit  for  mayhem  and  heavy 
damages. 

Modus  Operandi. — The  appendages  may  be  removed  through  the 
abdominal  wall  or  through  the  vagina :  the  former  method  is  called 

1  Polk  has  done  much  in  the  line  of  conservatism,  and  described  his  procedures 
in  Medical  Record,  Sept.  18,  1886 ;  Amer.  Jour.  Obst.,  1887,  vol.  xx.  p.  630 ;  Trans. 
Amer.  Gyn.  Soc.,  1887,  vol.  xii.  p.  128;  Jour.  Obst.,  Dec.,  1890;  ibidem,  Sept.,  1891; 
Tram.  Amer.  Gyn.  Soc.,  1893,  vol.  xviii.  p.  175;  Med.  News,  Jan.  4,  1896. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  535 

Tail's  operation,  the  latter  Battey's  operation.1  The  reader  is  referred 
to  the  general  description  of  laparotomy  given  under  Ovariotomy. 
Here  we  shall  add  a  few  points  with  regard  to  salpingo-oophorectomy. 

A.  Abdominal  salpingo-oopliorectomy. — The  incision  is  made  in  the 
median  line,  so  low  down  that  the  lower  end  is  half  an  inch  above 
the  symphysis.  The  upper  end  varies  according  to  circumstances. 
In  easy  cases  only  room  for  two  fingers  is  needed ;  in  difficult  it  may 
become  necessary  to  introduce  the  whole  hand,  push  the  intestines  up, 
and  expose  the  whole  pelvic  cavity  to  view. 

When  the  small  incision  is  made  in  the  abdominal  wall,  the  left 
fore-  and  middle  fingers  are  introduced  into  the  abdominal  cavity. 
Pushing  omentum  and  intestines  up,  the  fingers  are  placed  on  the 
fundus  uteri,  and  moved  out  along  one  of  the  tubes  to  the  ovary.  If 
there  are  no  adhesions,  the  tube  and  ovary  are  lifted  between  these  two 
fingers  up  through  the  abdominal  wound.  If  necessary  this  proce- 
dure may  be  facilitated  by  having  the  uterus  lifted  from  the  vagina 
by  means  of  a  dilator  introduced  into  the  cervix  or  simply  with  the 
fingers  of  an  assistant. 

In  this  and  other  operations  in  the  depth  of  the  pelvis  the  manipu- 
lations may  also  be  much  facilitated,  especially  on  the  left  side,  by 
introducing  a  colpeurynter,  i.  e.  a  rubber  bag,  into  the  rectum,  and 
distending  it  with  water.  If  oozing  points  are  left  in  the  pelvis 
after  the  operation,  this  same  bag  filled  with  ice-water  and  combined 
with  abdominal  compression  may  serve  as  a  hemostatic  plug  working 
both  by  pressure  and  refrigeration. 

If  the  broad  ligament  does  not  yield,  Tait  gains  room  by  making 
small  tears  in  it  with  his  nails  near  the  pelvic  wall.  The  peritoneum 
and  connective  tissue  are  torn,  but  the  stronger  vessels  resist.  The 
parts  to  be  removed  may  also  be  seized  beneath  the  surface  of  the 
body  with  suitably  curved  forceps,  and  ligated  there,  without  being 
brought  out  through  the  incision. 

If  there  are  adhesions  they  are  cautiously  torn,  the  surgeon,  if  pos- 
sible, relying  on  his  sense  of  touch  alone.  Otherwise,  they  are  lifted 
up  into  the  wound  and  separated  there.  Sometimes  it  is  necessary 
to  enlarge  the  incision  so  as  to  make  the  whole  pelvis  accessible  to 
the  eyes  and  hands.  The  intestines  are  pressed  up  under  the  abdominal 
wall,  and  held  there  with  a  flat  sponge  or  a  gauze  pad.  In  very  ex- 
ceptional cases  they  are  even  pulled  out  through  the  opening,  laid  on 
the  upper  abdomen,  and  covered  writh  a  cloth  wrung  out  of  hot  nor- 
mal salt  solution  (6  : 1000).  Trendelenburg's  position  helps  much  to 
avoid  the  handling  of  the  intestines,  which  is  apt  to  cause  shock  and 
predisposes  to  adhesions  after  the  operation. 

1  Battey's  operation  was  originally  devised  for  the  "  extirpation  of  the  functionally 
active  ovaries  for  the  remedy  of  otherwise  incurable  diseases"  (Trans.  Amer.  Gyn. 
Soc.,  1876,  vol.  i.  p.  101),  but  has  been  much  extended  both  as  to  object  and  method. 


536  DISEASES  OF  WOMEN. 

If  the  tube  and  ovary  are  imbedded  in  a  whole  mass  of  resistant 
new-formed  tissue  it  may  be  necessary  to  desist  from  their  removal, 
but  with  increasing  experience  and  skill  a  man  will  be  able  to  remove 
organs  which,  at  an  earlier  stage  of  his  career,  it  was  wise  to  leave 
undisturbed. 

Tait  does  not  give  up  the  operation  even  if  it  is  necessary  to  wound 
bladder  and  intestine  in  order  to  finish  it.  The  ensuing  fistula  heals 
spontaneously.1 

Sometimes  serous  fluid  accumulates  in  the  interior  of  adhesions  by 
which  they  become  tubular,  and  look  much  like  a  Fallopian  tube  or 
the  appendix  vermiformis. 

Vascular  bands  are  often  cut  between  two  ligatures. 
When  the  tube  and  ovary  are  lifted  up,  a  dull  handled  needle 
(Fig.  185,  a  p.  2 15)  threaded  with  a  strong  silk  ligature  (braided,  No. 
12),  20  inches  long,  is  pushed  from  the  front  backward  through  the 
broad  ligament,  half  to  three-fourths  of  an  inch  under  the  ovary.  An 
assistant  seizes  the  ligature  with  a  pair  of  forceps  and  his  fingers  and 
holds  it  while  the  operator  withdraws  the  needle.  Next,  the  loop 
is  brought  forward  over  the  ovary  and  tube,  comprising  as  much 
of  the  latter  as  feasible.  One  of  the  free  ends  is  carried  through 
this  loop,  the  other  remains  above  it.  The  operator  seizes  both  ends 
with  the  fingers  of  his  right  hand  and  pulls  on  them,  and  presses 
with  his  left  thumb  and  index  finger  against  the  tissue  to  be  li- 
gated.  He  may  also  pull  on  one  end  alone,  and  have  his  assistant 
pull  on  the  other,  or,  preferably,  he  may  combine  both  these  manipu- 
lations. The  ligature  is  pulled  very  tight, 
FIG.  281.  but  slowly,  so  as  not  to  break  it,  and  then 

tied  with  a  reef  knot.  This  way  of  tying  the 
ligature  is  called  the  Staffordshire  knot  (Fig. 
281),  because  it  is  the  badge  of  the  county  of 
Stafford  in  England.  It  is,  however,  safer 
and  allows  us  to  get  closer  up  to  the  uterus 
Staffordshire  Knot  (Tait).  to  cut  the  ligature  in  the  middle  and  cross 
the  halves  twice,  as  described  under  Ovariot- 
omy. From  each  side  a  pressure-forceps  is  put  on  the  pedicle  just 
above  the  ligature,  and  tube  and  ovary  are  cut  off  with  small  cuts 
made  with  a  pair  of  scissors  curved  on  the  flat,  taking  care  to  remove 
all  of  the  ovary  and  as  much  as  possible  of  the  tube ;  and,  on  the 
other  hand,  to  leave  enough  of  the  pedicle  to  prevent  the  ligature 
from  slipping.  Next,  one  of  the  pairs  of  forceps  is  removed,  and  a 
strong  tenaculum  or  tenaculum -forceps  inserted  in  its  stead.  Then 
the  second  forceps  is  taken  off.  If  there  is  no  bleeding  from  the 
stump,  the  ends  of  the  ligature  are  cut  short.  If  there  is  bleeding, 
the  ligature  is  carried  round  the  pedicle  and  tied  on  the  other  side. 

1  Lawson  Tait,  Centralblatt.  fiir  Gynak.,  Feb.  4,  1893,  vol.  xvii.  p.  93. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  537 

The  cut  surface  is  powdered  with  iodoforra  or  aristol,  or  seared  with 
the  thermo-cautery,  taking  great  care  not  to  burn  the  ligature.  Fi- 
nally, the  tenaculum  is  removed,  and  the  pedicle  dropped  into  the  pel- 
vic cavity.  If  there  is  too  much  tissue,  it  may  be  cut  off  under  the 
tenaculum. 

Instead  of  thus  including  a  large  part  of  the  broad  ligament  in  the 
ligature,  two  separate  ligatures  may  be  placed,  one  on  the  ovarian 
vessels  in  the  infundibulo-pelvic  ligament  and  the  other  on  the  anas- 
tomosis between  the  ovarian  and  the  uterine  artery,  just  outside  of 
the  corner  of  the  uterus.  Then  the  ovary  and  the  tube  may  be  cut 
off.  If,  exceptionally,  there  is  any  bleeding,  the  bleeding  point  is 
secured  by  a  special  ligature.  This  method  offers  the  great  advan- 
tages that  there  is  less  danger  of  the  ligatures  slipping,  that  very  little 
tissue  is  compressed  in  the  ligature,  that  all  ovarian  tissue  can  be  re- 
moved, and  that  there  is  no  traction  on  the  scar.1 

It  should  be  remembered  that  the  ovarian  vessels  at  the  brim  of 
the  pelvis  cross  in  front  of  the  ureter,  and  care  should  be  taken  not 
to  embrace  this  tube  in  the  ligature. 

If  the  tumor  is  situated  in  the  broad  ligament,  leaving  the  lower 
part  of  the  same  free,  this  may  be  tied  in  small  bundles,  between  two 
ligatures,  gaining  access  to  the  deeper  portion  by  gradually  cutting 
what  has  been  tied.  If  there  is  no  pedicle  at  all,  the  peritoneal  cov- 
ering of  the  tumor  must  be  split,  and  the  tumor  enucleated.  This 
leaves  a  sac  which  is  treated  as  described  above  (p.  499)  under  Fib- 
roids of  the  Uterus. 

As  to  the  treatment  of  the  appendages  of  the  other  side  there  is 
much  difference  of  opinions.  Tait  recommends  to  remove  them  even 
if  they  are  healthy,  because  they  will  be  affected  later,  and  the  second 
operation  has  a  mortality  altogether  disproportionate  to  the  first  pro- 
ceeding, while  many  die  for  want  of  a  second  operation.  Other  ope- 
rators, on  the  contrary,  have  even  tried  to  save  the  second  set  of  adnexa 
wrhen  they  were  found  diseased.  This  has  the  advantage  of  preserv- 
ing menstruation,  and  of  avoiding  the  mental  depression  sometimes 
following  the  removal  of  the  appendages  on  both  sides,  and  has  even, 
in  rare  cases,  led  to  pregnancy  and  childbirth.  When  offspring  is 
particularly  desirable  this  method  should,  therefore,  be  considered.2 

The  ovary  may  be  cut  open,  cysts  enucleated  or  part  of  the  ovary 
cut  out,  and  tiie  edges  united  by  a  continuous  catgut  suture.  A  piece 
of  the  tube  may  be  cut  off,  and  hemorrhage  arrested  by  ligating  the 
ala  vespertilionis  without  interfering  with  the  vessels  nourishing  the 
ovary.  An  opening  may  be  cut  in  the  tube,  and  the  mucous  mem- 
brane stitched  to  the  peritoneum  around  it  (p.  534). 

1  C.  B.  Penrose,  Amer.  Jour.  Obst.,  1895,  vol.  xxxii.  p.  221. 

2  Details  are  found  in  papers  by  A.  Martin,  Centralblatt  fur  Gynak.,  June  20,  1891, 
vol.  xv.  No.  25,  p.  515,  and  Polk,  Amer.  Jour.  Obst.,  Dec.,  1890,  vol.  xxiii.  p.  1375. 


538  DISEASES  OF  WOMEN. 

While  the  removal  of  non-adherent  appendages  is  a  comparatively 
easy  operation,  it  becomes  one  of  the  most  difficult  when  there  are 
many  extensive  and  unyielding  adhesions.  Great  benefit  may,  under 
these  circumstances,  be  derived  from  the  Trendelenburg  position  (p. 
138).  In  trying  to  free  the  adherent  appendages  we  must  try  to  find 
natural  lines  of  cleavage.  Remembering  that  the  ovary  springs  from 
the  posterior  layer  of  the  broad  ligament,  and  that  the  tube  is  situated 
at  the  upper  border  of  the  ligament  and  forms  a  curve  around  the 
ovary  (pp.  63,  65),  we  must  try  to  free  them  by  going  in  between 
them  and  the  sacrum  behind  the  broad  ligament.  If  possible  the 
ligature  should  be  passed  below  the  round  ligament,  which  lessens  the 
danger  of  its  slipping.  For  the  same  reason  the  broad  ligament  is 
slackened  in  drawing  the  ligatures  tight.  If  the  tissue  is  so  friable 
that  the  ligature  cuts  through  the  tube  and  ligament,  it  may  become 
necessary  to  form  a  pedicle  of  the  cornu  of  the  uterus  itself,  and  tie 
the  ovarian  artery  separately,  as  just  described. 

If  the  tube  or  ovary  or  both  contain  much  fluid,  it  may  be  well  to 
remove  it  with  the  aspirator,  in  order  to  avoid  rupturing  the  append- 
ages, but  if  feasible  the  removal  of  the  filled  organs  is  easier.  If  a 
rupture  occurs,  which  most  frequently  takes  place  in  the  upper  poste- 
rior part  of  the  wall  of  the  tube,  the  fluid  should  be  carefully  wiped 
off  and  a  drain  of  iodoform  gauze  carried  out  from  the  soiled  place 
through  the  abdominal  wound  or  the  vagina.  Only  if  the  fluid 
spreads  far  among  the  intestinal  knuckles,  the  whole  abdominal  cavity 
should  be  washed  out  with  copious  irrigations  of  hot  salt  solution,  and 
a  drain  left  in.  If  there  is  much  oozing,  a  drain  is  likewise  indicated, 
or  it  may  be  necessary  to  apply  a  Mikulicz  tampon  (p.  181). 

If  both  appendages  must  be  removed,  it  is  better  to  remove  the 
uterus  too.  This  organ  is  often  the  source  of  the  infection  of  the 
others.  It  is  not  only  useless  after  their  removal,  but  often  hemor- 
rhage and  pain  continue  after  the  removal  of  the  appendages.  Under 
such  circumstances  I  have  repeatedly  been  obliged  to  remove  the 
uterus  after  months  or  years. 

If  only  one  set  of  appendages  is  removed,  it  is,  as  a  rule,  well  to 
curet  the  uterus  at  the  same  time. 

The  mortality  after  salpingo-oophorectomy  has,  in  Tait's  hands, 
only  been  2.5  per  cent.  The  objection  that  the  operation  deprives  the 
patient  of  the  possibility  of  becoming  a  mother  has  not  much  weight, 
since  in  the  large  majority  of  cases  she  has  proved  to  be  or  would 
be  sterile  on  account  of  the  condition  of  the  ovaries  and  tubes. 
Her  sufferings  may  be  intolerable,  and  render  it  impossible  for  her 
to  earn  a  living  or  perform  any  useful  work.  Often  they  make  an 
opium-eater  of  her.  Now,  in  most  cases,  but,  it  must  be  admitted, 
not  in  all,  the  operation  restores  her  to  health  and  makes  her  again  a 
useful  member  of  her  household  and  the  community  at  large. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  539 

Immediate  and  demote  Results, — In  86  per  cent,  the  operation 
brings  on  the  menopause  at  once  or  after  a  few  months  (compare 
p.  119).  When  menstruation  continues  it  may  be  due  to  incomplete 
removal  of  the  appendages,  irritation  of  the  stumps,  or  disease  of  the 
uterus.  As  a  rule,  there  is  a  discharge  of  blood  for  several  days  fol- 
lowing the  operation,  which  is  accounted  for  by  the  unusual  congestion 
caused  by  the  ligature  cutting  oif  the  normal  roads  of  circulation. 
In  some  cases  a  hematoma  is  developed  in  the  broad  ligament.  Some- 
times, during  convalescence,  or  later,  an  encysted  collection  of  serous 
fluid  takes  place  in  pseudomembranes.  Many  complain  of  vertigo 
and  fulness  in  the  head,  which  may  be  relieved  by  bromides  or 
cauterization  with  Paquelin's  ther mo-cautery  on  the  nape  of  the  neck, 
or  which  may  even  necessitate  repeated  venesection. 

Purpura  hemorrhagica  has  been  observed  at  the  time  when  men- 
struation was  due,  but  the  operation  does  not  give  rise  to  vicarious 
menstruation. 

During  the  first  week  after  the  operation  most  patients  complain 
of  pain  in  the  pelvis,  which  probably  is  due  to  the  constriction  of 
the  pedicle.  In  some  this  pain  disappears  soon,  and  they  feel  relieved 
from  their  sufferings  and  bless  the  day  they  submitted  to  the  opera- 
tion. In  others  this  happy  event  does  not  occur  before  the  lapse  of 
several  months,  and  in  a  few  the  pain  persists  indefinitely.  This 
sad  condition  may  be  accounted  for  in  different  ways.  The  chronic 
peritonitis  had  extended  beyond  the  tubes  and  ovaries,  and  part  of  it 
remains,  therefore,  after  their  removal.  The  operation  itself  may 
lead  to  new  peritonitis.  New  adhesions  may  form  between  the 
stump  and  its  surrounding  parts.  In  several  cases  a  secondary  ope- 
ration has  shown  that  a  cyst  had  formed  near  the  stump  on  one  or 
both  sides.  Adhesions  to  the  bladder  may  cause  a  troublesome  desire 
to  urinate.  Those  to  the  intestines  may  cause  pain,  or  give  rise  to 
intestinal  occlusion.  In  some  cases  there  is  congestion  of  the  uterus 
causing  pain,  leucorrhea,  or  hemorrhage.  The  persistent  pelvic  pain 
is  best  treated  with  counter-irritation  or  galvanism,  and  sometimes  a 
second  laparotomy  is  performed  and  adhesions  disposed  of,  or  the 
uterus  has  to  be  removed,  if  it  was  not  done  when  the  appendages 
were  taken  out. 

The  sexual  appetite  may  remain  unchanged,  increase,  diminish,  or 
disappear.  Many  become  fat  and  dyspeptic. 

In  a  large  percentage  melancholia  has  developed,  but  alienists 
think  they  can  account  for  it  in  other  ways  than  by  charging  it 
directly  to  the  loss  of  the  genital  glands  and  the  cessation  of  men- 
struation. Even  if  the  mental  disturbance  does  not  go  so  far  as 
insanity,  despondency,  irritability,  and  laziness  are  quite  frequently 
observed. 

Congestions  of  the  head   and   thoracic  organs   and   perspiration 


540  DISEASES  OF  WOMEN. 

appear  soon  after  the  operation,  and  may  continue  with  lessening  fre- 
quency for  years.1 

Like  other  laparotomies  this  operation  may  cause  injury  to  a  ureter, 
ventral  hernia,  fecal  fistula,  an  abdominal  sinus  following  the  use  of 
the  drainage-tube,  and  intestinal  obstruction ;  or  it  may  aggravate  pre- 
existing diseases  in  other  organs,  all  of  which  has  to  be  considered 
before  determining  on  the  operation. 

B.  Vaginal  Salpingo-oophorectomy  presents  the  advantage  that  there 
is  less  shock  and  less  risk  of  causing  a  hernia,  but  it  has  the  draw- 
back that  the  field  of  operation  is  so  narrow  and  deep-seated.  Now, 
the  frequency  of  ventral  hernia  following  laparotomy  was  due  to  the 
hasty  and  imperfect  way  in  which  the  abdominal  wall  used  to  be 
closed,  and  can  to  a  great  extent  be  avoided  by  proper  care.  On  the 
other  hand,  the  abdominal  section  offers  the  immense  advantage  that 
if  necessary  every  part  of  the  pelvic  cavity  can  be  made  visible  and 
accessible,  and,  taking  into  consideration  howr  uncertain  the  diagnosis 
is  in  these  deep-seated  affections,  and  how  often  there  are  adhesions 
to  the  intestine  and  its  appendix,  that  is  a  point  of  paramount  import- 
ance. If  we  enter  through  the  abdominal  wall,  the  incision  may  be 
enlarged,  and  we  are  able  to  cope  with  every  arising  difficulty,  while 
when  entering  through  the  vagina  we  have  to  work  through  a  small 
opening  at  the  bottom  of  a  long  tube.  Without  speculum  and  retract- 
ors we  do  not  see  anything  at  all,  and  if  we  use  them,  they  block  the 
passage  for  our  fingers.  This  method  was  excellent  for  the  removal 
of  healthy  ovaries  and  at  a  time  when  lack  of  antiseptic  surgery  made 
the  opening  through  the  abdominal  wall  much  more  dangerous  than 
that  through  the  vagina,  but  for  the  needs  of  the  present  day,  when 
we  especially  wish  to  remove  diseased  tubes,  and  with  our  present 
resources  in  regard  to  hemostasis  and  drainage,  the  abdominal  method 
is  preferable.  If  the  appendages  of  both  sides  are  so  diseased  that  it 
is  sure  they  must  be  removed,  much  space  is  gained  by  first  extirpat- 
ing the  uterus  by  vaginal  section.  The  situation  of  the  appendages 
and  the  shape  of  the  pelvis  ought  also  to  have  great  weight  in  the 
choice  of  method  :  if  the  parts  to  be  removed  are  situated  near  or 
above  the  brim  of  the  pelvis,  or  if  the  pelvic  cavity  is  deep  and  nar- 
row, the  abdominal  method  may  be  the  only  available  one.  If,  on  the 
other  hand,  the  uterus  is  retroverted,  or  the  cervix  can  be  pulled  for- 
ward and  the  fundus  is  easily  forced  down  into  Douglas's  pouch,  the 
appendages  may  be  safely  removed  by  vaginal  section.  Under  these 
circumstances  there  will  seldom  be  trouble  from  intestinal  adhesions.2 

The  vagina  is  opened  by  anterior  or  posterior  colpotomy  or  both, 

1  The  results  of  salpingo  oophorectomy  have   been   discussed  by  Coe,  Medical 
Record,  April  19,  1890;  by  Boldt,  ibidem,  May  17,  1890;  and  Lusk,  Amer.  Jour. 
Obst.,  Nov.,  1891. 

2  Henry  T.  Byford  of  Chicago,  Amer.  Jour.  Obst.,  March,  1892,  p.  337. 


DISEASES  OF  THE  FALLOPIAN  TUBES.  541 

and  in  order  to  gain  more  room  an  incision  in  the  median  line  may 
be  carried  from  the  posterior  transverse  incision  as  far  down  as  the 
bottom  of  the  pouch  of  Douglas,  after  which  the  operator  works 
mostly  witli  his  forefinger,  until  he  can  plunge  it  into  the  peritoneal 
cavity.  Adhesions  are  torn  and  the  appendages  brought  down  and 
ligated.  Hemorrhage  is  stopped  by  the  same  means  as  when  laparot- 
omy  is  performed,  and  the  wound  is  closed  or  left  open.  (See  Hys- 
terectomy for  Uterine  Fibroids.) 

Cystic  Salpingitis. 

When  a  considerable  amount  of  fluid  distends  the  tube,  it  forms  a 
cyst.  The  abdominal  ostium  is  closed,  the  uterine  may  yet  remain 
open.  The  cyst  forms  a  tumor  situated  to  the  side  of  and  above  the 
uterus,  whence  it  may  extend  up  into  the  abdominal  cavity  or  down 
between  the  layers  of  the  broad  ligaments.  The  swelling  may  be 
club-shaped,  with  a  narrower  inner  and  a  wider  outer  end ;  or  it  may 
be  more  globular  and  be  bound  to  the  uterus  with  a  narrow  pedicle, 
corresponding  to  the  inner  undilated  part  of  the  tube ;  or  it  may  be 
divided  by  external  bands  or  inner  partitions  into  a  series  of  com- 
partments, which  gives  it  the  appearance  of  a  string  of  sausages. 

The  contents  vary  much,  but  may  be  divided  into  three  chief  classes 
according  to  the  preponderating  element — namely,  pus,  blood  or  serum. 
Often  different  kinds  are  found  in  the  same  individual. 

Symptoms. — When  salpingitis  leads  to  the  formation  of  a  cyst,  pres- 
sure-symptoms are  added  to  those  due  to  inflammation.  The  patient 
complains  of  heaviness  and  a  bearing-down  sensation,  meteorism,  con- 
stipation, often  combined  with  a  frequent  desire  for  defecation  and 
micturition,  which  is  an  inconvenience  in  daytime  and  disturbs  her 
rest  at  night.  Sometimes  there  is  a  constant  slight  discharge  of  blood 
from  the  uterus.  She  has  pain  in  the  inguinal  and  sacral  regions,  and 
repeated  attacks  of  peritonitis. 

By  bimanual  examination  a  tumor  of  the  description  just  given  is 
felt  which  may  be  movable  or  immovable,  more  frequently  the  latter. 

Diagnosis. — The  diagnosis  between  cystic  salpingitis  and  certain 
other  diseases  may  be  difficult  or  impossible.  Tubal  pregnancy  forms 
a  similar  globular  tumor  fastened  to  the  cornu  of  the  uterus.  The 
history,  the  presence  of  signs  of  pregnancy,  the  expulsion  of  shreds 
of  a  decidua,  and  attacks  of  sudden  pain  so  violent  as  to  make 
the  patient  scream  and  sink  down  on  the  floor  may,  however,  enable 
us  to  make  the  diagnosis  of  tubal  pregnancy. 

An  ovarian  cyst,  be  it  pedunculated  or  intraligamentous,  may  be 
entirely  like  cystic  salpingitis;  but  sometimes  the  ovary  may  be  felt 
beside  the  cystic  tube,  and  the  history  of  the  case  may  give  useful 
information. 

Cysts  of  the  broad  ligament  are  less  painful,  hardly  tender,  immov- 


542  DISEASES  OF  WOMEN. 

able,  and  tip  the  uterus  to  the  opposite  side.  A  peritonitic  exudation 
causes  a  constant  pain,  is  immovable,  and  pushes  the  uterus  forward 
and  downward,  but  all  this  may  also  be  found  in  cystic  salpingitis. 
A  uterine  fibi'oid  may  form  a  similar  tumor  either  in  the  abdominal 
cavity  or  between  the  layers  of  the  broad  ligament,  but  it  is  harder, 
never  fluctuating,  and  the  depth  of  the  uterine  cavity  is  increased. 
A  uterine  fibro-cyst  is  in  closer  connection  with  the  uterus,  and  the 
sound  reveals  an  increased  depth  of  the  uterine  canal.  Swollen  pelvic 
glands  may  give  a  similar  history  and  form  a  similar  tumor.  Aspi- 
ration may  give  information  about  the  presence  and  nature  of  fluid, 
but  ought  not  to  be  used  unless  the  tumor  is  adherent  to  the  abdomi- 
nal wrall  or  the  vaginal  vault. 

The  differential  diagnosis  between  the  three  kinds  of  cyst  may  also 
be  very  obscure,  although  certain  circumstances  may  point  more  dis- 
tinctly to  one  rather  than  to  the  others.  Thus  pyosalpinx  is  by  far 
more  common,  follows  gonorrheal  or  puerperal  infection,  is  very  adher- 
ent and  tender,  often  causes  fever,  and  is  apt  to  form  fistula.  Like 
hydrosalpinx  it  is  usually  bilateral. 

Hydrosalpinx  may  form  a  tumor  of  much  larger  size.  As  a  rule, 
it  is  less  adherent  and  less  tender,  and  causes  less  constitutional 
disturbance. 

Hematosalpinx  is  exceedingly  rare,  is  often  unilateral,  and  may  be 
accompanied  by  a  constant  bloody  discharge  from  the  uterus.  Some- 
times it  is  combined  with  hematocolpos  and  hematometra. 

Treatment. — As  a  rule,  the  cystic  tube  with  the  ovary  should  be 
removed.  An  exploratory  laparotomy  should  be  performed.  If  the 
cyst  is  large,  it  is  well  to  empty  it  with  trocar  or  aspirator,  and  close 
the  opening  with  pressure-forceps  before  extirpating  the  tumor.  If 
it  is  small,  it  may  be  removed  in  toto.  Some  prefer  the  removal 
through  the  vagina,  which  also  may  begin  as  an  exploratory  incision. 

The  arrest  of  hemorrhage  may  be  very  troublesome.  It  has  become 
necessary  to  leave  pressure-forceps  in  the  abdominal  cavity  till  the 
next  day,  and  even  to  perform  hysterectomy,  but  as  a  rule  the  opera- 
tor will  be  able  to  control  bleeding  by  the  usual  means :  tying  of 
arteries,  temporary  compression  with  forceps,  sponges,  or  compresses, 
flushing  the  abdominal  cavity  with  hot  water  (p.  182),  uniting  perito- 
neal edges  with  a  continuous  suture  of  catgut,  stitching  other  bleeding 
places  in  a  similar  way  (p.  499),  and  permanent  compression  with 
iodoform  gauze  with  or  without  counter-pressure  in  the  vagina 
(p.  181).  (Compare  Treatment  of  Intraligamentous  Ovarian  Cysts.) 

Broad  adhesions  are  often  better  separated  with  a  sponge  than  with 
the  fingers.  Band-like  adhesions  should  be  tied  near  both-  ends  and 
cut  away,  as  their  presence  later  might  give  rise  to  intestinal  obstruc- 
tion. If  there  are  many  adhesions,  the  removal  of  the  cyst  is  some- 
times facilitated  by  cutting  the  tube  between  two  ligatures  near  the 


DISEASES  OF  THE  FALLOPIAN  TUBES.  543 

inner  end,  and  proceeding  outward  instead  of  going  from  the  infundi- 
bulopelvic  ligament  and  the  pelvic  wall  toward  the  uterus.  In 
order  to  guard  against  infection  it  is  best  to  cut  the  tube  with 
Paquelin's  thermo-cautery  or  sear  the  ends  after  having  cut  with 
knife  or  scissors. 

The  prognosis  for  the  operation  is  better  in  hydro-  and  hematosal- 
pinx  than  in  pyosalpinx. 

Besides  these  considerations  applying  to  cystic  salpingitis  in  general, 
each  of  the  three  varieties  offers  some  peculiarities. 

Pyosalpinx. 

Pyosalpinx  is  that  form  of  cystic  salpingitis  in  which  the  contents 
are  purulent.  The  name  is  only  used  if  an  appreciable  cyst  has 
been  formed,  while  a  small  amount  of  pus  in  the  tube  simply 
constitutes  purulent  salpingitis.  The  cyst  has  in  most  cases  the  size 
of  a  Bartlett  pear,  but  may  be  as  large  as  a  fetal  head  at  term  or 
even  a  cocoanut.  The  wall  is  in  general  thickened,  but  has  thin 
places,  especially  upward  and  backward,  where  the  cyst  is  apt  to 
burst  during  the  operation  for  its  removal.  The  abdominal  ostium  is 
closed  by  agglutination  of  the  fimbria3  among  themselves  or  to  the 
ovary.  The  uterine  ostium  may  yet  be  open.  As  a  rule,  the  cyst  is 
adherent  'way  down  in  Douglas's  pouch.  The  uterus  is  often  retro- 
flexed. 

The  fluid  is  thick  pus,  sometimes  of  a  dirty  color  and  offensive 
odor,  due  to  the  neighborhood  of  the  intestine.  In  the  course  of 
time  it  may  change,  blood  being  admixed  with  it  by  hemorrhages 
from  the  wall,  or  it  may  become  inspissated  to  a  putty-like  mass,  or 
the  cellular  elements  may  be  absorbed,  leaving  a  more  serous  or 
mucoid  fluid. 

If  left  alone,  the  cyst  may.  rupture  and  discharge  its  contents  into 
the  peritoneal  cavity,  causing  sudden  death,  or  in  between  the  layers  ^ 
of  the  broad  ligament,  whence  it  may  find  an  outlet  through  the 
rectum,  the  vagina,  the  bladder,  or  the  skin,  either  above  or  below 
Poupart's  ligament,  or  in  the  gluteal  region.  Such  rupture  often 
leaves  a  fistulous  tract  with  no  tendency  to  heal,  the  continued  dis- 
charge exhausting  the  patient. 

Treatment. — Some  puncture  with  the  aspirating  needle  from  the 
vagina,  the  rectum,  or  the  skin,  according  to  the  situation  of  the  cyst, 
and  when  pus  appears  they  follow  the  puncture  up  with  an  incision. 
This  method  only  deserves  consideration  if  the  cyst  is  situated  in  the 
bottom  of  Douglas's  pouch,  and  is  firmly  adherent,  and  the  other  set 
of  appendages  seems  to  be  healthy.  It  may  be  drained,  as  stated 
above  (p.  511),  irrigated  with  antiseptic  fluids,  injected  with  tincture 
of  iodine,  touched  with  a  stick  of  nitrate  of  silver,  or  painted  with 


544  DISEASES  OF  WOMEN. 

iodized  phenol  (a  mixture  of  iodine  1  part  and  crystallized  carbolic 
acid  4  parts),  but  the  absce&s  may  continue  to  discharge  for  many 
months. 

Most  operators  prefer  laparotomy,  either  in  one  sitting  or  in  two 
acts.  By  the  latter  method  the  sac  is  made  to  adhere  to  the  abdomi- 
nal wall  before  it  is  opened.  The  common  way  is  to  operate  in  one 
sitting,  guard  the  peritoneal  cavity  against  the  entrance  of  pus  by 
means  of  large  sponges  or  gauze  compresses,  and,  if  it  has  entered, 
wash  it  out  with  plenty  of  warm  normal  salt  solution  and  extirpate 
the  sac. 

Some  prefer  the  vaginal  extirpation,  as  a  rule,  beginning  with  hys- 
terectomy. By  this  method,  however,  it  is  often  impossible  to  remove 
the  cyst.  Then  a  large  incision  is  made  into  it,  and  it  is  packed  with 
iodoform  gauze,  which  acts  as  a  drain,  and  later  may  be  replaced  by 
a  double-current  soft-rubber  drain. 

Hydrosalpinx. 

In  hydrosalpinx  the  fluid  is  serous,  mucous,  or  pultaceous.  Some- 
times it  contains  cholesterine.  The  wall  is,  as  a  rule,  thin  and  trans- 
lucent. This  variety  of  cystic  salpingitis  is  less  apt  to  become  adhe- 
rent and  is,  therefore,  often  movable.  Like  pyosalpinx  it  is  in  general 
bilateral,  but  it  develops  more  slowly,  gives  rise  to  less  pain,  and 
may  become  larger.  In  most  cases  it  is  not  larger  than  a  pear,  but 
it  sometimes  reaches  the  size  of  a  fetal  head  at  term,  and  may  even 
form  a  very  large  cyst  (Fig.  282).  Even  if  only  one  side  is  aifected 
the  patient  is,  as  a  rule,  sterile.  Often  hydrosalpinx  is  accompanied 
by  a  cystic  degeneration  of  the  ovary,  and  through  inflammation  it 
may  become  adherent  to  an  ovarian  cyst,  which  may  make  an  im- 
pression as  if  the  hydrosalpinx  itself  were  of  unusual  size.  Rupture 
of  the  sac  is  an  exceedingly  rare  event,  and  the  general  condition  is 
much  better  than  in  pyosalpinx.  It  is  probably  the  remnant  of  an 
old  catarrhal  or,  perhaps,  even  a  purulent  salpingitis.  The  diagnosis 
might,  perhaps,  be  made  surer  by  aspirating  the  fluid,  but,  being  less 
adherent,  hydrosalpinx  is  less  fit  for  this  operation.  We  might  find 
ciliated  columnar  epithelium  in  the  fluid,  but  that  may  also  be  found 
in  certain  ovarian  cysts. 

Treatment. —  A  small  cyst  of  this  kind  may  give  so  little  trouble 
that  it  may  be  left  alone.  Sometimes  aspiration  through  the  vagina 
may  effect  a  cure.  The  tumor  may  be  emptied  by  means  of  an  incis- 
ion made  in  the  vagina  and  drained,  but  this  process  may  prove  a 
tedious  one.  In  most  cases  laparotomy  is  performed  and  the  tumor  is 
removed.  If  the  tumor  is  not  very  large,  and  the  ovaries  are  in  a  fair 
condition,  an  attempt  may  be  made  to  save  one  or  both  sets  of  append- 
ages (p.  533). 


DISEASES  OF  THE  FALLOPIAN  TUBES.  545 

FIG.  282. 


Hydrosalpinx. 

Hematosalpinx. 

Hematosalpinx  is  the  name  of  a  cyst  formed  by  the  tube  and  filled 
with  blood.  There  are  two  forms :  in  one  the  blood  is  not  coagulated, 
but  kept  fluid  by  admixture  with  alkaline  secretion  from  the  inside  of 
the  tube;  in  the  other  is  found  a  laminated  fibrinous  clot  due  to 
successive  hemorrhages.  In  the  former  the  wall  need  not  undergo 
much  change,  and  the  blood  may  be  reabsorbed ;  in  the  latter  the 
wall  is  much  thickened.  The  effused  blood  may  be  inspissated  to  a 
syrupy  mass  or  changed  to  pus,  and  the  wall  may  ulcerate  and  finally 
rupture,  an  accident  which  is  much  more  common  with  hematosalpinx 
than  with  hydrosalpinx,  and  has  to  be  guarded  against  in  operating 
for  atresia  of  the  genital  canal  (p.  327). 

Etiology. — Exaiithematous  and  infectious  diseases,  phosphorus-poi- 

1  Specimen  from  my  operation  on  Mrs.  A.  N in  St.  Mark's  Hospital,  on  April 

30,  1892.     In  this  case  a  unilateral  hydrosalpinx  formed  a  tumor  filling  the  pelvis 
and  reaching  to  the  level  of  the  umbilicus. 
35 


546  DISEASES  OF  WOMEN. 

soniug,  extensive  burns,  and  diseases  of  the  heart,  lungs,  and  kidneys, 
may  cause  ecchyraosis  or  slight  hemorrhage  into  the  tubes. 

In  pyosalpinx  hemorrhage  may  take  place  from  the  wall,  and  blood 
mix  with  the  pus. 

When  there  is  an  occlusion  of  the  genital  canal,  the  menstrual  blood 
which  normally  is  secreted  in  the  tubes  (p.  118)  is  retained  and  forms 
hematosalpinx  combined  with  hematocolpos  and  hematornetra,  al- 
though the  communication  between  the  tube  and  the  uterus  may  be 
interrupted  (p.  326). 

Hematosalpinx  may  also  be  due  to  a  uterine  fibroid  or  an  inflamed 
ovary,  causing  salpingitis  by  extension  of  the  inflammation  of  the  endo- 
metrium  or  the  ovary  and  closing  the  tube,  or  it  may  be  a  reflex  effect 
of  an  extra-uterine  pregnancy  in  the  other  tube. 

Treatment. — Small  tumors  need  no  treatment.  In  that  form  which 
contains  fluid  blood,  laparotomy  or  colpotomy  may  be  performed,  the 
tube  cleaned  out,  made  perviable,  and  allowed  to  remain  (p.  533).  If 
the  cystic  tube  has  developed  down  between  the  layers  of  the  broad 
ligament,  which  may  be  supposed  when  it  is  low  down  and  immovable, 
an  incision  may  be  made  in  the  vaginal  vault  and  the  cyst  drained. 
Large  tumors  filled  with  clots  or*  blood  mixed  with  pus  should  be 
removed  by  laparotomy.  The  same  procedure  becomes  necessary 
after  the  operation  for  atresia  of  the  genital  canal,  if  it  has  not  pre- 
ceded it  (p.  327). 

CHAPTER  III. 
DISPLACEMENTS. 

THE  tube  may  be  found  in  a  crural  or  inguinal  hernia,  and  is  then 
generally  accompanied  by  the  ovary. 

In  the  higher  degrees  of  inversion  of  the  uterus  the  tubes  are 
always  drawn  into  the  sac  formed  by  the  inverted  uterus  (p.  462). 


CHAPTER  IV. 

NEOPLASMS. 

THE  neoplasms  of  the  tubes  are  not  of  much  practical  interest,  as 
they  often  cannot  be  diagnosticated,  are  so  small  that  they  do  no  harm, 
or  appear  together  with  affections  of  greater  importance  in  the  neigh- 
boring organs. 

A.  Cysts. — Real  cysts,  which  are  something  entirely  different  from 
cystic  salpingitis  (p.  541),  may  be  found  in  all  three  layers  composing 
the  wall  of  the  tube.  They  range  in  size  from  a  millet-seed  to  a  wal- 
nut, and  contain  a  citrine,  serous  fluid.  They  are  seen  very  frequently 


DISEASES  OF  THE  FALLOPIAN  TUBES.  547 

in  laparotomies  and  autopsies.  One  of  them  situated  at  the  abdominal 
end  of  the  tube  is  so  common  that  it  is  described  in  works  on  normal 
anatomy  under  the  name  of  the  hydatid  of  Morgagni  (p.  30).  Some 
of  these  cysts  are  doubtless  remnants  of  the  Wolffiau  body  (p.  20),  and 
others  are  the  result  of  extravasations  of  blood.1 

The  fluid  contained  in  them  is  so  bland  that,  even  if  through  a 
rupture  in  the  wall  it  should  find  its  way  into  the  peritoneum,  it 
could  hardly  do  any  harm. 

B.  Fibroma. — Myomatous  and  fibrous  tumors  like  those  of  the 
uterus  (p.  468)  are  formed  in  the  muscular  coat,  but  do  not,  as  a  rule, 
acquire  surgical  dimensions.     In  one  case,  however,  the  growth  had 
reached  the  size  of  a  fetal  head  at  term. 

C.  Lipoma. — Fatty  tumors  of  the  size  of  a  bean  to  that  of  a  walnut 
have  been  found  at  the  lower  side. 

D.  Papillomu,  a  real  neoplasm,  must  not  be  confounded  with  the 
growth  of  the  mucous  membrane  due  to   simple  hyperplasia  and 
hypertrophy  accompanying  salpingitis  (p.  525).    Papillomatous  tumors 
may  close,  dilate,  and  even  rupture  the  tube,  in  which  latter  case  a 
papillomatous  infection  would  be  likely  to  take  place  in  the  peri- 
toneum.    They  are  commonly  small,  but  may  reach  the  size  of  an 
orange. 

E.  Cancer,  either  carcinoma  or  sarcoma,  may  occur  primarily  in 
the  tubes,  but  is  nearly  always  secondary  to  cancer  of  the  uterus  or 
the  ovary. 

The  disease  makes  its  appearance  about  the  time  of  the  menopause, 
and  develops  slowly.  It  gives  rise  to  a  sanious  discharge  from  the 
vagina,  which,  in  connection  with  the  presence  of  a  tumor  and  the 
absence  of  signs  of  uterine  or  vaginal  cancer,  may  lead  to  a  diagnosis. 
As  a  rule,  it  is  not  recognized  before  an  autopsy  is  made. 

If  it  can  be  diagnosticated  in  life,  the,  tube  and  ovary  should  be 
removed  by  laparotomy. 

F.  Tuberculosis. — The  Fallopian  tube  is  more  apt  than  any  other 
part  of  the  genital  apparatus  to  be  the  seat  of  tuberculosis.     In  fact 
the  tubes  are  affected  in  nearly  all  cases  of  tuberculosis  of  the  genital 
tract,  and  genital  tuberculosis  is  much  more  common  than  was  for- 
merly surmised. 

It  may  be  primary  in  this  locality,  and  is  then  probably  due  to 
infection  through  the  semen  of  a  tuberculous  man.  Much  more  fre- 
quently, however,  it  is  secondary,  following  tubercular  peritonitis  or 
being  the  effect  of  infection  through  the  blood  in  persons  suffering 
from  phthisis.  As  a  rule,  both  tubes  are  affected. 

The  wall  is  swollen,  its  epithelium  is  thrown  off,  the  ostia  are 
generally  closed,  the  caliber  is  enlarged,  and  the  tube  is  filled  with  a 

1  This  was  so  in  a  case  of  chronic  oophoritis  and  salpingitis  operated  on  by  me  and 
examined  miscroscopically  by  Charles  Heitzmann. 


548  DISEASES  OF  WOMEN. 

caseous  mass.  The  microscope  reveals  the  characteristic  formation  of 
tubercles  in  the  wall — nuclei  centering  around  giant  cells — and  the 
presence  of  Koch's  bacillus  in  the  tissue  and  in  the  secretion.  Often 
the  peritoneum  in  the  vicinity  is  studded  with  miliary  tubercles.  In 
advanced  cases  the  whole  mucous  membrane  is  destroyed.  The  tubes 
are  in  general  out  of  place,  often  drawn  down  along  the  edges  of  the 
uterus,  and  bound  to  neighboring  parts  by  adhesions.  They  may 
form  tumors  as  large  as  a  goose-egg,  the  shape  of  which  is  that  of  a 
sausage,  a  club,  or  most  frequently  a  string  of  3  to  5  beads,  the 
single  knobs  of  which  are  round  or  oval  and  hard,  while  in  pyosal- 
pinx  they  are  soft.  Another  point  of  difference  between  the  two  is 
that  in  pyosalpinx  the  part  of  the  tube  situated  near  the  uterus  is 
nearly  always  free,  while  in  tuberculosis  the  disease  affects  this  part 
and  even  the  intramural  portion  as  well. 

Sometimes  tubes,  ovaries,  and  uterus  are  all  matted  together  by 
exudation  into  one  large  mass. 

The  disease  is  very  rarely  acute;  in  general  it  has  a  chronic  course. 

The  symptoms  are  like  those  of  salpingitis. 

The  diagnosis  is  often  obscure ;  but  occasionally  it  may  be  made  by 
reference  to  hereditary  predisposition ;  by  finding  signs  of  tuberculosis 
in  other  parts,  especially  the  lungs ;  by  finding  caseous  masses  and 
bacilli  in  the  vaginal  secretion ;  and  by  the  peculiarities  of  the  tumor 
just  mentioned. 

Treatment.  — As  a  prophylaxis  connection  with  a  man  affected  with 
tuberculosis  should  be  avoided.  The  hygienic  and  medical  treatment 
is  the  same  as  for  tuberculosis  in  general.  If  the  general  condition 
of  the  patient  is  not  too  bad,  saipingo-oophorectomy  may  perhaps 
effect  a  cure;  but  on  account  of  the  adhesions  the  operation  is 
often  difficult  and  sometimes  impossible.  If  the  uterus  participates 
in  the  degeneration,  this  may  be  removed  together  with  the  tubes  and 
ovaries.  But  as  it  is  uncertain  if  all  affected  tissue  has  been  removed, 
and  as  the  operation  itself  by  rupture  of  the  tube  and  entrance  of  its 
contents  into  the  peritoneal  cavity  may  spread  the  infection,  the  treat- 
ment, upon  the  whole,  is  unsatisfactory.  The  presence  of  tubercular 
peritonitis  or  a  mild  degree  of  phthisis  is  no  contraindication  for  the 
operation.1 

1  An  exhaustive  monograph  by  J.  W.  Williams  on  "  Tuberculosis  of  the  Female 
Generative  Organs"  is  published  in  Johns  Hopkins  Hospital  Report  in  Pathology, 
ii.,  Baltimore,  1892,  pp.  85-144. 


PART  VI. 

DISEASES  OF  THE  OVARIES. 


CHAPTER  I. 
MALFORMATIONS. 

Excessive  Growth. — The  ovaries  of  new-born  children  may  have 
twice  the  normal  size,  which  may  either  be  due  to  a  uniform  hyper- 
plasia  of  all  the  constituent  parts,  or,  more  frequently,  to  fetal  inflam- 
mation, resulting  in  a  preponderance  of  connective  tissue  and  a  partial 
or  total  disappearance  of  the  Graafian  follicles. 

Supernumerary  Ovaries. — Small  globular,  pedunculated  bodies  of 
the  same  structure  as  the  normal  ovaries,  and  varying  in  size  from 
that  of  a  pea  to  that  of  a  hazelnut,  are  found  in  5  per  cent,  of  all 
bodies  of  women.  These  small  ovaries  are  situated  near  the  peri- 
toneal border  of  the  normal  ovaries. 

An  ovary  may  be  more  or  less  completely  divided  into  two  parts 
by  fissures.  In  a  unique  case  there  were  even  found  three  large 
ovaries,  each  bound  to  the  uterus  with  a  separate  ligament. 

The  possibility  of  supernumerary  ovaries  must  be  kept  in  mind 
in  order  to  explain  the  persistence  of  menstruation  after  the  extir- 
pation of  both  ovaries  (pp.  119  and  539),  the  presence  of  two  nor- 
mal ovaries  besides  an  ovarian  cyst,  and  the  occurrence  of  pregnancy 
after  double  ovariotomy  —  phenomena  which  have  actually  been 
observed.1 

Absence  or  Rudimentary  Development. — Both  ovaries  may  be  absent, 
a  condition  which  usually  is  combined  with  absence  of  the  uterus. 
One  ovary  may  be  absent  in  cases  of  uterus  unicornis. 

More  common  than  the  total  absence  is  a  rudimentary  development 
of  the  ovary.  Such  rudimentary  ovaries  may  or  may  not  contain 
Graafian  follicles.  In  the  latter  case  they  consist,  only  of  connective 
tissue  and  smooth  muscle-fibers. 

As  a  rule,  the  rudimentary  condition  is  found  in  connection  with 
an  arrest  of  development  of  the  uterus,  but  it  may  also  be  found  when 

1  For  details  see  my  article  on  "  Malformations  of  the  Female  Genitals,"  in  Ame>: 
System  of  Gynecology,  edited  by  Mann,  vol.  i.  p.  236. 

549 


550  DISEASES  OF  WOMEN. 

the  uterus  is  normal.  Women  without  Graafian  follicles  do  not  men- 
struate, and  are  sterile,  but  may  have  sexual  desire  and  a  perfect  female 
type. 

Rudimentary  ovaries  are  often  found  together  with  an  imperfect 
development  of  the  large  blood-vessels,  especially  -the  aorta,  or  of  the 
central  nervous  system,  especially  in  idiots  and  cretins. 


CHAPTER  II. 
DISPLACEMENTS. 

ONE  or  both  ovaries  may  occupy  an  abnormal  position.  In  its 
unusual  place  the  ovary  may  have  preserved  its  normal  connections, 
or  it  may  have  been  cut  off  altogether  from  the  broad  ligament  by  an 
inflammatory  process  in  fetal  life.  It  may  then  either  float  about  as 
a  small  hard  body  in  the  abdominal  cavity  or  it  may  become  fastened 
to  the  lower  border  of  the  omentum. 

If  the  displaced  ovary  retains  its  normal  connections  with  the  ala 
vespertilionis  and  the  tube,  it  may  be  found  outside  the  pelvis  or 
remain  in  it. 

Extrapdvic  Displacements. — It  may  be  found  in  the  lumbar  region, 
or,  passing  through  the  same  openings  as  other  hernise,  it  may  occupy 
the  inguinal  canal  or  the  labium  majus  (inguinal  hernia) ;  the  ante- 
rior side  of  the  thigh  below  Poupart's  ligament  (o-ural  hernia) ; 
the  gluteal  region  (gluteal  hernia) ;  the  depth  of  the  anterior  wall  of 
the  pelvis  (obturator  hernia),  or  the  anterior  surface  of  the  abdomen 
(ventral  hernia). 

The  position  of  the  ovary  in  the  lumbar  region  is  very  rare.  It  is 
due  to  a  lack  of  descent  (p.  23),  and  is  only  found  together  with  a 
considerable  arrest  of  development  in  other  respects. 

Inguinal  hernia  of  the  ovary  may  be  congenital  or  acquired.  The 
congenital  may  be  due  to  a  deficient  development  of  the  round  liga- 
ment, by  which  the  ovary,  tube,  and  sometimes  one  horn  of  a  uterus 
bicornis  and  part  of  the  omentum  are  pulled  through  the  canal  of 
Nuck. 

More  rarely  the  ovary  alone  is  found  in  a  congenital  inguinal  her- 
nia, into  which  it  easily  drops  during  intra-uterine  life  on  account 
of  being  much  smaller  than  the  caliber  of  the  canal  of  Nuck. 

The  acquired  form  can  only  occur  if  the  tube  and  the  infundi- 
bulopelvic  ligament  are  unusually  elongated  and  lax,  and  may 
then  be  produced  by  a  fall  or  similar  violence. 

In  its  abnormal  place  the  ovary  may  become  inflamed  or  undergo 
cystic  or  cancerous  degeneration. 

Congenital  inguinal  hernia  cannot  be  replaced.     It  may  be  pro- 


DISEASES  OF  THE  OVARIES.  551 

tected  by  a  hollow  pad  or,  if  it  gives  trouble,  it  may  be  extirpated. 
The  acquired  form  may  be  brought  back  through  the  canal  and  kept 
back  by  means  of  a  truss  or  the  radical  operation  for  hernia.  If  it 
cannot  pass  the  canal,  herniotomy  should  be  performed.  If  the  ovary 
is  seriously  diseased,  it  should  be  extirpated. 

Crural  ovarian  hernia  is  always  acquired.  If  the  ovary  cannot  be 
replaced  by  taxis,  herniotomy  should  be  performed,  after  which  a 
truss  should  be  applied.  It  should  only  be  removed,  if  it  is  so  seri- 
ously affected  that  medical  and  palliative  treatment  must  be  without 
avail. 

The  other  herniae  through  natural  openings  are  exceedingly  rare. 
The  ovary  may  be  found  in  a  ventral  hernia  after  laparotomy,  and 
would  offer  a  special  indication  for  operating  on  the  hernia. 

The  ovaries  may  also  be  drawn  with  the  tubes  into  the  funnel  of 
an  inverted  uterus  (p.  462). 

While  the  preceding  displacements  are  anatomical  or  surgical  curi- 
osities, the  intrapelvic  displacement  or  prolapse  of  the  ovary,  is  a  com- 
mon disease  of  considerable  practical  importance.1 

The  normal  ovaries  may  frequently  be  palpated  in  their  normal 
situation  by  bimanual  vagi  no-abdominal  examination.  They  may 
likewise  be  felt  by  recto-abdominal  examination,  but  the  latter 
offers  no  advantage  except  in  intact  virgins  or  women  with  atresia  of 
the  vagina. 

When  the  ovary  becomes  displaced  it  sinks  backward,  downward, 
and  inward,  describing  an  arc  with  the  ligament  of  the  ovary  as  a 
radius  and  its  insertion  on  the  uterus  as  a  center.  Thus  it  sinks 
first  down  on  the  retro-ovarian  shelf  (p.  91),  and  next  into  Doug- 
las's pouch,  and  may  sink  as  low  down  as  the  level  of  the  os 
uteri. 

Etiology. — The  left  ovary  is  much  more  frequently  prolapsed  than 
the  right,  the  cause  of  which  is  probably  to  be  sought  chiefly  in  the 
absence  of  a  valve  in  the  ovarian  vein  on  this  side,  and  its  opening 
into  the  renal  vein  under  a  right  angle — circumstances  that  favor 
passive  hyperemia  in  the  gland  and  predispose  to  disease  (p.  74). 
The  presence  of  the  rectum  on  the  left  side  and  the  motion  of  hard 
fecal  lumps  downward  help  also  to  dislodge  the  ovary. 

The  mere  increase  in  weight  of  the  ovary  is  sufficient  to  cause  it 
to  prolapse,  as  is  proved  by  cases  in  which,  after  the  subsidence  of 
swelling,  the  organ  returns  to  its  normal  place.  It  may  be  pushed 
out  of  place  by  tumors  or  drawn  down  by  a  retroverted  or  retro- 
flexed  uterus  or  by  adhesions  remaining  after  pelvic  peritonitis.  It 
may  also  sink  on  account  of  insufficient  support  from  below,  espe- 
cially rupture  of  the  vaginal  entrance  (p.  305). 

1  This  disease  has  been  treated  of  in  an  exhaustive  way  by  P.  F.  Munde,  Trans. 
Amer.  Oyn.  Soc.,  1879,  vol.  iv.  p.  164  et  seq. 


552  DISEASES  OF  WOMEN. 

Prolonged  sexual  irritation  may  cause  the  prolapse  by  producing 
hyperemia. 

Pregnancy  offers  particularly  favorable  circumstances  for  the  pro- 
duction of  prolapse,  since  the  ovaries  are  enlarged  and  ascend  into 
the  abdomen,  and  their  attachments  become  softened  and  elongated. 
Inflammation  and  beginning  cystic  degeneration  increase  the  weight, 
and  are  often  the  cause  of  adhesions. 

Whether  a  normal  ovary  can  become  prolapsed  by  a  fall  or  similar 
injury,  as  is  the  case  with  the  uterus  (p.  454),  is  doubtful,  but  if  it 
is  enlarged  beforehand,  such  a  traumatic  impulse  is  enough  to  cause 
the  displacement. 

Prolapse  of  the  ovary  is  frequently  associated  with  acquired  ante- 
flexion  of  the  uterus,  the  cause  of  both  troubles  being  probably  sub- 
involution  after  pregnancy  and  the  concomitant  lack  of  tonus  in  the 
tissues. 

It  is  also  often  combined  with  tubal  disease. 

Symptoms. — The  symptoms  are  those  of  chronic  oophoritis  com- 
bined with  those  due  to  the  abnormal  position  of  the  ovary.  Hypere- 
mia, edema,  and  inflammation  may  be  both  the  cause  and  the  effect 
of  the  displacement.  The  patient  complains  of  pain  in  the  sides  of 
the  pelvis,  the  sacral  region,  or  the  rectum,  often  shooting  down  to 
the  knee  and  up  into  the  hip.  It  gets  worse  when  she  walks,  pre- 
vents her  from  standing  for  any  length  of  time,  and  is  sometimes 
aggravated  by  sitting  down.  It  is  also  increased  very  much  by  pal- 
pation, and  may  continue  through  the  whole  day  upon  which  the  ex- 
amination has  been  made.  This  great  tenderness  also  renders  coition 
painful  or  impossible,  and  causes  great  pain  during  the  passage  of 
hard  fecal  masses,  and  often  painful  tenesmus  after  they  have  been 
expelled. 

Menstruation  is,  as  a  rule,  painful  and  often  too  profuse. 

Nausea  and  vomiting  are  not  rare.  The  whole  nervous  system 
suffers  much.  The  patient  is  tired,  despondent,  and  irritable.  Some- 
times she  may  even  have  attacks  of  epilepsy. 

Diagnosis. — The  diagnosis  is,  as  a  rule,  easily  made  by  bimanual 
examination,  when  the  ovary  is  recognized  by  its  shape,  its  connection 
with  the  uterus,  its  great  sensitiveness  if  it  is  inflamed,  or  at  least  a 
sickening  feeling  on  pressure  if  it  is  normal.  If  the  ovary  is  situated 
on  the  retro-ovarian  shelf,  it  is  felt  best  by  examining  the  patient  in 
the  left-side  position  and  pressing  the  perineum  well  back. 

The  swollen  tube  has  a  more  sausage-like  shape.  A  small  pedun- 
culated  fibroid  of  the  uterus  is  harder  and  not  sensitive.  Remnants 
of  pelvic  inflammation  are  more  diffuse  and  less  tender.  Sci/bala  are 
less  tender,  may  often  be  indented  or  crushed,  and  may  be  removed 
by  enemas  and  aperient  medicines. 

Prognosis. — The  displaced  ovary  is  liable  to  become  inflamed  or 


DISEASES  OF  THE  OVARIES.  553 

cystic.  If  it  is  movable,  the  prognosis  is  comparatively  good ;  but  if 
it  is  bound  in  its  new  position  by  adhesions,  the  treatment  will  at  best 
be  a  very  protracted  one,  and  a  cure  is  doubtful. 

Treatment. — The  two  chief  indications  are  to  combat  hyperemia 
and  inflammation  and  to  replace  and  retain  the  ovary  in  its  normal 
place.  The  first  is  aimed  at  by  rest,  keeping  the  bowels  open  (p.  225), 
prohibiting  sexual  connection,  prescribing  hot  vaginal  douches  (p. 
171),  using  scarification  of  the  cervical  portion  (p.  186),  making 
applications  of  iodine  (p.  170),  or  inserting  pledgets  with  ichthyol- 
glycerin  (p.  178)  into  the  vagina,  or  by  means  of  galvanism  with  the 
positive  pole  in  the  vagina  (p.  232). 

The  displaced  organ  should  be  replaced  as  soon  as  feasible,  but 
sometimes  the  above-mentioned  measures  must  be  taken  first  before 
the  ovary  recovers  sufficiently  to  be  able  to  bear  the  pressure  of  a 
pessary. 

The  ovary  is  best  replaced  in  the  genu-pectoral  posture  (p.  138), 
and  if  it  cannot  be  replaced  or  retained  at  once,  the  daily  use  of  this 
posture  and  a  glass  tube  admitting  the  air  into  the  vagina  (p.  447) 
may  prepare  the  way  for  its  final  replacement. 

If  the  ovary  is  adherent,  it  is  necessary  first  to  try  to  bring  about 
the  stretching  and  absorption  of  the  adhesions.  This  is  done  by 
packing  the  vagina  (p.  178).  If  the  ovary  is  very  tender  at  first, 
perhaps  only  a  single  cotton  ball  will  be  tolerated,  but  gradually 
more  are  put  in,  so  as  to  lift  the  ovary  up  in  the  pelvis. 

Massage  (p.  190)  is  also  a  powerful  means  of  stretching  and  break- 
ing up  adhesions. 

The  galvanic  current  has,  in  consequence  of  its  electrolytic  property 
(p.  232),  a  similar  effect.  , 

Schultze's  method  is  somewhat  similar  to  that  used  by  the  same 
author  for  uterine  adhesions  (p.  450).  The  forefinger  is  introduced 
into  the  rectum  of  the  anesthetized  patient  in  the  lithotomy  position, 
and  bored  in  between  the  ovary  and  its  surroundings,  while  the  uterus 
is  grasped  with  the  other  hand  through  the  abdominal  wall  and  pulled 
upward. 

The  retention  of  the  ovary  in  its  normal  position  is  often  more 
difficult  than  its  replacement.  Sometimes  Thomas's  hard-rubber  bulb- 
pessary,  essentially  a  Hodge  pessary  (Fig.  250,  p.  446)  with  a 
thickened  upper  arch,  answers  a  good  purpose.  Special  pessaries  of 
hard  rubber  with  a  crossbar  of  unusual  width,  or  with  a  notch  in  the 
middle  or  a  corner  cut  off,  have  been  constructed  for  this  condition.1 

In  cases  in  which  no  hard  pessary  can  be  tolerated,  one  of  whale- 
bone covered  with  soft  rubber  (p.  447)  may  be  tried. 

If  these  measures  fail,  we  may  have  recourse  to  cutting  operations. 
If  the  uterus  is  retroverted  or  retroflexed,  it  may  be  brought  forward 
1  See  the  above-mentioned  article  by  Munde. 


554  DISEASES  OF  WOMEN. 

by  shortening  the  round  ligaments  (p.  448)  or  fastening  the  fundus 
uteri  to  the  abdominal  wall  (p.  452). 

If  the  uterus  is  not  displaced,  but  the  ovarian  displacement  is  due 
to  an  elongation  of  the  infundibulopelvic  ligament,  that  may  be 
shortened  by  taking  a  reef  in  it  (p.  453). 

But  if  the  ovary,  besides  being  prolapsed,  is  diseased,  the  proper 
thing  to  do  is  to  perform  salpingo-oophorectomy,  especially  by  vagi- 
nal section  (p.  453). 


CHAPTER    III. 
HYPEREMIA  AND  HEMATOMA. 

A  NORMAL  hyperemia  doubtless  takes  place  in  the  ovary  during 
coition  in  consequence  of  contraction  of  the  unstriped  muscle-fibers 
of  the  broad  ligament  (p.  57),  and  contributes  to  the  expulsion  of  the 
ovum  (p.  74).  A  similar  normal  hyperemia  probably  returns  at 
regular  intervals,  -corresponding  to  menstruation.  At  least  the  gen- 
eral blood-pressure  of  the  whole  system  is  increased  before  menstrua- 
tion sets  in  (p.  117),  and  in  some  women  a  very  considerable  increase 
in  size  may  be  found  alternately  in  one  ovary  or  the  other  at  the 
menstrual  periods  (p.  120).  An  effusion  of  blood  also  takes  place 
normally  into  the  ruptured  follicle  after  the  expulsion  of  the  ovum 
(p.  71). 

Pathological  Anatomy. — Abnormal  hemorrhage  may  take  place 
into  the  Graafian  follicles  or  into  the  stroma  of  the  ovary,  the  fol- 
licular  being  much  more  common  than  the  stromal.  Follicular  hem- 
orrhage forms  a  tumor  that  is  rarely  larger  than  a  hazelnut  (Fig.  283), 
but  may  reach  the  size  of  a  walnut. 

The  ovary  is  only  moderately  enlarged  and  a  little  more  resistant. 
If  many  follicles  are  filled  with  blood  at  the  same  time,  it  is  dark  and 
studded  all  over  the  surface  with  small  protuberances.  The  sac  is 
thinned  on  the  side  nearest  the  surface.  The  contents  are  dark,  thin 
blood  mixed  with  clots.  In  the  course  of  time  it  may  change  into 
a  thick  chocolate-colored  fluid,  which  may  be  of  the  consistency  of 
honey.  The  fluid  part  may  be  absorbed  altogether,  leaving  a  granular 
pigment ;  or  the  solid  parts  may  be  absorbed,  so  that  only  a  cyst  filled 
with  serous  fluid  remains ;  or  suppuration  may  set  in.  As  a  rule,  the 
follicle  does  not  burst,  but  the  ovum  is  destroyed. 

Stromal  hemorrhage  may  cause  so  small  an  extravasation  of  blood 
that  it  can  only  be  seen  with  the  microscope,  but  it  may  impart  a  red- 
dish color  to  the  ovary,  and  even  show  as  minute  red  points  oh  the  cut 
surface.  On  the  other  hand,  it  may  gradually,  by  repeated  new  escapes 
of  blood,  destroy  the  whole  tissue  of  the  ovary,  and  form  a  hematoma 
as  large  as  a  man's  fist  or  a  child's  head.  In  other  cases  the  tissue  is 


DISEASES  OF  THE  OVARIES.  555 

preserved,  but  so  infiltrated  with  blood  that  the  whole  ovary  is  like  a 
sponge  soaked  in  blood.  Such  enlarged  ovaries  are  bound  by  adhes- 
ions to  the  neighboring  organs.  The  stromal  hemorrhage  may  be 
primary  or  follow  as  a  secondary  event  after  follicular  apoplexy. 

FIG.  283. 


Hematoma  of  Ovary  (a  little  less  than  natural  size) :  a,  follicular  hematoma,  12  millimeters 
in  diameter,  inner  measure ;  fresh  blood -clot  easily  separated  from  the  surrounding  wall, 
situated  in  the  outer  end  of  the  ovary,  one-half  of  it  touching  the  stroma,  the  other  half 
covered  with  a  layer  varying  from  2  to  3  millimeters  in  thickness,  without  any  opening; 
W>,  dilated  follicles  with  serous  contents ;  c,  Fallopian  tube.1 

Any  extensive  hemorrhage  may  cause  rupture  of  the  ovary,  the 
blood  pouring  into  the  peritoneal  cavity  or  penetrating  between  the 
two  layers  of  the  broad  ligament.  The  extravasated  blood  under- 
goes changes  similar  to  those  just  described  for  the  follicular  form. 

Etiology. — Hyperemia  and  hematoma  of  the  ovary  may  be  due  to 
any  thing  that  causes  venous  stasis,  such  as  masturbation  or  venereal 
excesses,  heart  disease,  pulmonary  phthisis,  cerebral  apoplexy,  tumors, 
adhesions  compressing  the  veins,  or  torsion  of  the  ala  vespertilionis. 

Secondly,  they  may  be  referable  to  dissolution  of  the  blood,  such  as 
occurs  in  severe  burns,  phosphorus-poisoning,  typhoid  fever,  puer- 
peral septicemia,  scurvy,  etc. 

1  Left  ovary  from  my  salpingo-oophorectomy  on  Mrs.  P in  St.  Mark's  Hospital, 

Nov.  29,  1892.       The  right  ovary   contained  a  serous  cyst  measuring  2  cm.  in 
diameter. 


556  DISEASES  OF  WOMEN. 

Thirdly,  hematoraa  may  be  developed  from  gyroma,1  which  is  the 
same  as  corpus  albicans  (p.  74),  and  may  be  the  terminal  stage  of  a 
corpus  luteum,  or  tinder  influence  of  chronic  oophoritis  may  represent 
the  first  stage  of  an  endothelioma,  an  abnormal  formation,  which  will  be 
described  under  Oophoritis.  Gyroma  may  occasionally  lead  to  the 
formation  of  a  hematoma,  and  endothelioma  does  so  quite  frequently. 

Symptoms. — A  patient  affected  with  hyperemia  of  the  ovary  is 
liable  to  suffer  from  menorrhagia.  At  the  time  of  menstruation  she 
is  seized  with  sudden  pain  in  the  region  of  the  ovaries,  extending 
down  the  thighs,  and  sometimes  accompanied  by  neuralgia  of  the 
breasts.  She  has  no  fever. 

Hemorrhage  in  the  ovary  may  take  place  without  giving  rise  to 
symptoms.  If  the  collection  is  large,  it  causes  pain,  nausea,  vom- 
iting, and  the  ovary  is  felt  to  be  enlarged.  If  rupture  occurs,  the 
usual  symptoms  of  internal  hemorrhage  are  present,  such  as  shock, 
pallor,  abdominal  pain,  a  cold  clammy  skin,  and  a  weak,  rapid  pulse. 
If  a  large  hematocele  is  formed,  a  fluctuating  swelling  can  be  felt 
through  the  abdominal  wall  and  the  vagina. 

Diagnosis. — Hyperemia  or  apoplexy  may  be  diagnosticated,  if  in  a 
healthy  person  one  or  both  ovaries  suddenly  become  enlarged  and 
tender  without  fever.  In  a  patient  affected  with  blood-dissolution 
the  apoplexy  may  be  inferred,  if  she  suddenly  is  seized  with  ovarian 
pain,  and  a  movable  tumor  can  be  felt  in  the  pelvis. 

A  periodical  increase  of  suffering  at  the  time  of  menstruation  in  a 
person  with  diseased  ovaries  is  a  sign  of  congestion. 

The  sudden  appearance  of  the  signs  of  internal  hemorrhage  in 
such  a  person  denotes  that  rupture  of  the  ovary  has  taken  place. 

An  extravasation  of  blood  into  the  broad  ligament  does  not  extend 
so  high  up  as  the  tumor  formed  by  intraperitoneal  hemorrhage;  indeed, 
it  often  forms  a  tumor  at  the  base  of  the  broad  ligament. 

A  swollen  Fallopian  tube  often  is  more  sausage-shaped,  whereas 
the  ovary  is  more  round. 

Sometimes  an  aspirating  needle  may  be  thrust  in  through  the  vagi- 
nal roof,  and  the  bloody  fluid  will  then  help  to  establish  a  diagnosis. 

Prognosis. — Hyperemia  can,  as  a  rule,  be  cured.  Hematoma  may 
also  be  absorbed,  but  occasionally  a  rupture  occurs,  which  may  end 
fatally.  If  due  to  endothelioma,  the  whole  constitution  suffers,  and 
grave  nervous  symptoms  are  developed.  The  normal  ovarian  tissue 
disappears  gradually,  and  the  ova  are  destroyed. 

Treatment. — In  hyperemia,  rest,  inclusive  of  physiological  rest — 

1  This  subject  was  first  treated  by  Dr.  Mary  Dixon  Jones,  and  later  by  Dr- 
Francis  Foerster  and  Dr.  H.  J.  Boldt,  all  working  under  the  egfs  of  Dr.  C- 
Heitzmann:  Jones,  N.  Y.  Med.  Jour.,  Sept.  28,  1889,  May  10-17,  1890;  Times 
and  Register,  Apr.  30,  1892;  Foerster,  Amer.  Jour.  Obst.,  May,  1892,  vol.  xxv.  p. 
577 ;  Boldt,  International  Med.  Congresx,  Berlin,  1890,  and  Deutsche  med.  Wochenschr., 
1890. 


DISEASES  OF  THE  OVARIES.  557 

that  is  to  say,  abstinence  from  sexual  excitement — is  of  great  import- 
ance. 

The  general  health  should  be  improved  by  means  of  hygienic 
measures  and  tonics  (p.  225).  The  nervous  system  may  be  quieted 
by  the  use  of  bromides.  A  derivation  to  the  skin  by  means  of  blis- 
ters may  be  useful.  The  bowels  should  be  kept  open.  In  girls  of 
ardent  temperament  or  with  bad  habits  marriage  may  answer  a  good 
purpose.  The  usual  treatment  for  pelvic  inflammation,  such  as  the 
use  of  hot  douches,  painting  with  tincture  of  iodine,  tampons  with 
ichthyol-glycerin  or  plain  glycerin,  or  the  galvanic  current,  should  be 
instituted.  If  there  is  an  acute  attack,  the  patient  should  stay  in 
bed,  have  an  ice-bag  on  the  hypogastric  region,  and  be  given  mor- 
phine enough  to  combat  pain.  If  the  ovaries  have  suffered  much  in 
their  structure,  it  may  even  become  necessary  to  remove  them.  When 
symptoms  of  rupture  are  present,  laparotomy  should  be  performed  at 
once,  and  the  ovary  from  which  the  hemorrhage  comes  should  be 
extirpated  together  with  its  tube.  The  other  ovary  should  be  left, 
if  it  is  not  seriously  diseased. 


CHAPTER    IV. 

OOPHORITIS. 

OOPHORITIS,  the  inflammation  of  the  ovary,  may  be  acute  or 
chronic. 

A.  Acute  Oophoritis  and  Ovarian  Abscess. 

The  inflammation  may  begin  on  the  surface, — -perioophoritis, — which 
is  identical  with  local  peritonitis  (although  the  ovary  has  no  perito- 
neal covering,  p.  65),  in  the  follicles, — -folllcular  oophoritis, — or  in 
the  stroma, — interfollicular  oophoritis, — -just  as  we  have  seen  in  regard 
to  hemorrhage,  with  which  it  is  in  many  cases  connected  in  such  a 
way  that  it  is  difficult  to  say  which  has  preceded  the  other.  The 
distinctive  anatomical  feature  is  here,  as  in  the  inflammation  of  other 
parts  of  the  body,  the  infiltration  of  the  tissue  with  small  round  cells, 
and,  if  suppuration  supervenes,  the  presence  of  pus-corpuscles.  To 
the  naked  eye  the  condition  is  in  the  beginning  much  like  hyperemia ; 
the  ovary  is  enlarged  and  impregnated  with  a  reddish  fluid ;  later 
yellow  points  and  streaks  appear;  and  finally  these  melt  together, 
and  an  abscess  is  formed.  Of  these  there  may  be  one  or  more.  In 
puerperal  and  gonorrheal  cases  usually  both  sides  are  affected ;  in 
others,  as  a  rule,  only  one  ovary  is  inflamed. 


558  DISEASES  OF   WOMEN. 

Before  pus  is  formed  the  inflammation  may  end  in  resolution,  but 
the  ovary  rarely  returns  completely  to  its  pristine  condition.  As  a 
rule,  it  remains  enlarged  by  formation  of  new  connective  tissue  or 
becomes  smaller  by  subsequent  cicatricial  retraction — cirrhosis. 

The  ovum  and  the  epithelium  of  the  follicles  undergo  fatty  degen- 
eration. Sometimes  they  are  transformed  into  small  cysts  with  thick- 
ened walls,  or  they  are  destroyed,  leaving  a  cicatrix.  An  abscess 
may  destroy  the  whole  ovary.  As  a  rule,  plastic  lymph  is  thrown 
out  as  a  superficial  covering  over  the  abscess  in  the  depth  of  the 
ovary,  and  thus  the  organism  is  protected,  but  rupture  may  take 
place  into  the  peritoneal  cavity  and  cause  general  peritonitis.  The 
pus  in  an  ovarian  abscess  may  be  "  laudable"  or  have  an  offensive 
odor  due  to  absorption  of  gas  from  the  rectum.  It  may  become 
inspissated,  and  finally  form  an  innocuous  calcareous  mass. 

Etiology. — Extensive  oophoritis  is  a  rare  disease  outside  of  the 
puerperal  state.  It  may  be  primary  or  secondary.  The  primary 
may  be  caused  by  hyperemia  and  hematoma  of  the  ovary  (p.  554), 
by  sexual  excesses,  or  by  sudden  suppression  of  the  menstrual  flow 
(pp.  129,  238).  It  may  also  appear  as  part  of  a  constitutional  dis- 
ease, such  as  the  eruptive  fevers,  cholera,  septicemia — whether  puer- 
peral or  not — and  poisoning  with  phosphorus  or  arsenic.  It  may 
follow  minor  operations,  such  as  the  use  of  the  sound,  the  incision 
of  the  cervix,  trachelorrhaphy,  etc.  The  common  course  is  that  the 
inflammation  first  attacks  the  endometrium,  then  the  tubes,  and  finally 
extends  to  the  ovary ;  but  it  may  also  reach  the  ovaries  directly  through 
the  lymphatics. 

An  ovarian  abscess  may  even  be  due  to  a  needle  finding  its  way 
from  the  intestine  into  the  ovary.1 

Secondary  oophoritis  may  also  follow  after  peritonitis,  and  most 
frequently  it  is  due  to  gonorrheal  infection,  which  latter  works  its 
way  up  from  the  vagina  through  the  uterus  and  tubes. 

Symptoms. — In  most  cases  the  symptoms  are  obscured  by  those  of 
the  accompanying  disease,  especially  salpingitis  or  peritonitis.  But 
sometimes  it  is  possible  to  feel  the  ovary  to  be  enlarged.  It  is  the 
seat  of  a  burning  pain,  radiating  down  to  the  knee,  to  the  bladder, 
and  the  rectum,  and  it  is  exceedingly  tender  to  the  touch.  The 
knee  on  the  affected  side  is  sometimes  drawn  up ;  occasionally  there 
is  a  reflex  pain  in  the  breast,  and  nearly  always  nausea.  Like 
orchitis  in  the  male,  oophoritis  may  alternate  with  mumps. 

An  ovarian  abscess  gives  rise  to  recurrent  attacks  of  chills  and  fever. 
Sometimes  the  swollen  ovary  can  be  felt,  and  perhaps  even  fluctuation 
can  be  made  out.  The  abscess  may  open  into  the  peritoneal  cavity, 
the  intestine,  especially  the  sigmoid  flexure,  the  bladder,  less  fre- 
quently into  the  vagina,  and  rarely  even  through  the  abdominal  wall. 
1  Frank  W.  Haviland,  New  York  Med.  Record,  Oct.  2,  1892,  vol.  xlii.  p.  398. 


DISEASES  OF  THE  OVARIES.  559 

Diagnosis. — It  is  seldom  possible  to  make  an  entirely  sure  diag- 
nosis. This  can  only  be  done  if  we  feel  the  enlarged  and  tender 
ovary.  In  a  suppurating  ovarian  cyst  the  symptoms  are  less  acute. 
Salpingitis  and  pyosalpinx  are  sausage-shaped,  the  inflamed  ovary  and 
ovarian  abscess  globular.  Pelvic  abscess  is  situated  lower  down  and 
absolutely  immovable,  while  the  ovarian  abscess  may  be  more  or  less 
movable. 

Prognosis. — The  prognosis  in  the  common  non-septic,  acute  oopho- 
ritis  is,  upon  the  whole,  favorable  as  to  life,  even  if  the  disease  rarely 
ends  in  complete  resolution.  The  inflammation  may  subside  in  four  or 
five  days.  The  septic  form  is  apt  to  form  an  abscess,  and  it  is  not 
rare  that  the  abscess  bursts  into  the  abdominal  cavity  and  causes  death 
from  septic  peritonitis.  If  the  abscess  opens  into  the  gut,  the  opening 
may  close  speedily,  but  sometimes  a  fistulous  communication  remains, 
which  may  give  rise  to  exhausting  fever.  Since  we  have  seen  that 
the  ova  are  liable  to  degenerate,  we  can  understand  that  oophoritis 
often  leads  to  sterility.  One  attack  is  frequently  followed  by  others, 
so-called  chronic  oophoritis. 

Treatment. — The  patient  must  be  kept  quiet  in  bed.  An  ice-bag 
is  applied  over  the  affected  part  (p.  1 87).  The  bowels  should  be  kept 
open  with  saline  aperients  (p.  225).  Pain  is  to  be  combated  with  opi- 
ates, preferably  hypodermic  injections  of  morphine. 

If  the  symptoms  indicate  the  presence  of  an  abscess,  the  ovary 
should  be  removed,  either  by  abdominal  or  vaginal  section.  Even 
if  the  ovary  is  adherent,  the  adhesions  are  fresh  and  can  in  all 
likelihood  be  separated.  Some  prefer,  however,  under  these  cir- 
cumstances, if  the  ovary  is  within  easy  reach,  to  aspirate,  make  an 
incision,  and  drain  from  the  vagina. 

B.   Chronic  Oophoritis. 

By  chronic  oophoritis  is  understood  a  chronic  condition  charac- 
terized by  the  remains  of  acute  inflammation  of  and  in  contact 
with  the  ovary,  congestion,  and  repeated  attacks  of  acute  inflam- 
mation. 

Pathological  Anatomy. — In  most  cases  the  ovary  is  enlarged  to  two 
or  three  times  its  normal  size,  and  has  an  oval  or  globular  shape. 
In  others  it  is  smaller  than  normal,  forming  an  irregular  shriveled 
mass.  Very  frequently  it  is  more  or  less  cystic  (Fig.  284).  The 
capillaries  increase  in  size  from  the  periphery  toward  the  center,  form- 
ing a  structure  like  that  of  erectile  bodies.  The  anastomosis  between 
the  ovarian  and  the  uterine  artery  is  dilated,  which  may  explain  the 
endometritis  so  often  found  combined  with  chronic  oophoritis.  The 
ovisacs  and  the  ova  are  often  diseased  or  disappear.  First  medullary 
corpuscles  are  developed,  and  the  yolk  and  the  gerrainative  vesicle 


560 


DISEASES  OF  WOMEN. 


break  down,  leaving  a  granular  mass ;  later  fibrous  connective  tissue 
replaces  the  whole  structure. 

Sometimes  the  ovum  undergoes  colloid  or  waxy  degeneration.     The 


FIG.  284. 


FIG.  285. 


'-a 


Chronic  Oophoritis :  a,  cut  surface  of  ovary  studded  with  cysts ;  b,  tube ;  c,  pedunculated 
cyst  hanging  from  the  mesosalpinx.1 

follicles  may  be  transformed  into  cysts  with  a  thickened  wall  and 
surrounded  by  indurated  tissue.     The  albuginea  is  thickened,  and 

often  covered  with  an  adhesive  layer 
of  peri  tonic  origin.  A  single  cyst  may 
reach  the  size  of  an  English  walnut, 
and  cause  the  absorption  of  the  rest  of 
the  organ,  so  that  the  ovary  is  changed 
to  an  ovarian  cyst.  The  fluid  is  se- 
rous and  yellowish,  or  may  by  admix- 
ture of  blood  become  thick  and  brown. 
The  stroma  of  the  ovary  is  harder,  of 
a  white  color,  and  shows  hyperplasia 
of  fibrous  connective  tissue.  The 
hyperplastic  ovary  is  generally  free ; 
the  atrophic,  on  the  contrary,  im- 
bedded in  adhesions,  to  the  pressure 
of  which  its  dwindling  probably  is  due. 

The  formation  of  cysts  is  probably  caused  by  congestion  at  the  men- 
strual period,  if  the  blood-pressure  is  insufficient  to  rupture  the  fol- 
licle or  the  rupture  is  prevented  by  the  thickening  of  the, albuginea, 
perioophoritic  adhesions,  or  the  too  deep  situation  of  the  follicle  in  the 


c- — 


Chronic  Oophoritis  (natural  size) :  a,  cor- 
pus luteum  changed  into  cyst ;  b,b,  yel- 
low masses  with  remnant  of  central 
cavity ;  c,c,  corpora  nigra :  d,  albuginea. 


1  Specimen  from  my  salpingo-oophorectomy  on  Mrs.  C. 
pital,  on  June  9,  1891. 


in  St.  Mark's  Hos- 


DISEASES  OF  THE  OVARIES.  561 

stroma.  Sometimes  it  can  be  seen  that  the  cyst  has  formed  in  a 
corpus  luteum  (Fig.  285).1 

Etiology. — Chronic  oophoritis  is  by  far  more  common  than  acute. 
Often  the  acute  inflammation  forms  the  starting-point,  and  the  reader 
is,  therefore,  referred  to  what  has  been  said  above  (p.  558)  in  regard 
to  the  causes  of  that  aifection. 

The  disease  is  found  most  commonly  in  young  women  between 
twenty  and  thirty  years  of  age.  The  left  side  is  oftener  affected 
than  the  right  for  the  same  reasons  that  we  have  given  for  the 
greater  frequency  of  prolapse  on  this  side  (p.  551).  A  misplaced 
ovary  is  indeed  more  liable  to  the  development  of  chronic  oophoritis 
than  one  in  its  normal  situation.  For  the  same  reason  retroflexion 
of  the  womb  predisposes  to  it.  It  is  often  found  together  with  an 
ovarian  cyst  on  the  other  side. 

Ordinarily,  chronic  oophoritis  is  due  to  puerperal  or  gonorrheal 
infection.  Other  factors  are  venereal  excesses,  masturbation,  and 
perhaps,  unsatisfied  desire.  The  abuse  of  alcoholic  beverages  seems 
also  to  produce  the  disease.  Working  on  sewing-machines  causes 
pelvic  congestion,  and  may,  therefore,  become  a  cause  of  chronic 
oophoritis.  Syphilis  has  also  been  thought  to  be  a  cause  of  the  dis- 
ease— a  supposition  that  has  much  to  recommend  it  when  we  think 
of  the  frequency  with  which  that  disease  localizes  in  other  glands, 
and  especially  of  the  analogy  with  syphilitic  orchitis. 

Nothing  is  more  common  than  to  find  extra vasated  blood  by 
microscopical  examination  of  even  apparently  healthy  ovaries,  and 
larger  collections  of  this  kind  can  hardly  fail  to  elicit  an  inflammatory 
reaction  in  the  surrounding  tissue.  Thus  hyperemia  and  hematoma 
may  lead  to  chronic  inflammation  of  the  ovarian  tissue,  and  to  the 
formation  of  cysts  (p.  559). 

Symptoms. — The  symptoms  are,  as  a  rule,  more  or  less  masked  by 
inflammation  in  the  surroundings,  especially  salpiugitis  and  local 
peritonitis,  as  well  as  retroflexion  of  the  uterus. 

Very  frequently  both  ovaries  are  affected. 

The  patient  complains  of  pain  in  one  or  both  iliac  fossa?,  to  which 
often  sacral  pain  is  added.  At  times  it  extends  with  a  neuralgic 
character  to  the  rectum,  the  bladder,  the  hip,  and  down  to  the  knee. 

1  Besides  the  large  corpus  luteum  which  has  been  transformed  into  a  cyst  are 
found  numerous  small,  generally  oblong,  yellow  masses,  in  the  centre  of  which  traces 
of  a  cavity  are  still  discernible,  and  two  corpora  nigra  (p.  74). 

For  want  of  a  more  suitable  place,  I  wish  here  to  refer  to  the  calcification  of  cor- 
pora IvJLe/a.  Concretions  of  the  bright  yellow  color  characteristic  of  the  recent  corpus 
luteum  have  been  found  imbedded  either  directly  in  the  stroma  of  the  ovary  or  sur- 
rounded by  a  cyst-wall.  They  consist  of  a  dense  tissue  impregnated  with  lime-salts. 
Occasionally  these  hard  bodies  may  even  be  felt  through  the  vaginal  wall,  and  give 
rise  to  the  impression  that  one  has  to  deal  with  the  sac  of  extra-uterine  gestation, 
containing  fragments  of  bone  (Bland  Sutton,  Amer.  Jour.  Obst.,  Dec.  1892,  vol.  xxxvi, 
p.  908,  and  H.  C.  Coe,  ibidem,  Feb.,  1892,  vol.  xxv.  p.  246). 
36 


562  DISEASES  OF  WOMEN. 

The  whole  leg  may  feel  heavy.  The  pain  is  always  increased  at  the 
approach  of  the  menstrual  period,  and  often  during  intercourse — espe- 
cially if  the  uterus  is  retroflexed  and  the  ovaries  prolapsed — or  during 
defecation  and  micturition.  Any  kind  of  exertion  is  badly  borne. 
Some  patients  can  hardly  stand  or  walk  for  any  length  of  time.  In 
rare  cases  the  pain  appears  regularly  in  the  middle  of  the  intermen- 
strual  period.  (Compare  p.  417.) 

Menstruation  is  often  irregular  and  too  profuse.  When  the  follicles 
and  ova  are  destroyed,  there  follows,  on  the  contrary,  a  stage  of 
amenorrhea. 

Very  often  these  patients  are  sterile  or  become  so  secondarily  after 
the  confinement  or  the  abortion  that  gave  rise  to  the  disease. 

Leucorrhea  is  quite  common.  The  digestion  suffers,  the  patient 
loses  flesh,  and  the  nervous  system  is  much  upset — disorders  which 
may  end  in  hysteria  or  hystero-epilepsy. 

A  woman  of  the  laboring  class  affected  with  this  disease  undergoes 
an  enormous  amount  of  suffering,  and  her  wealthy  sister  may  by 
invalidism  be  confined  to  her  bed  or  her  room  for  months  or  years. 

Diagnosis. — Often  it  is  very  difficult  or  impossible  to  tell  if  a  mass 
we  feel  through  the  roof  of  the  vagina  is  an  ovary  or  a  tube,  or 
both  matted  together  in  one  mass  by  peritonitic  exudation.  Some- 
times we  can,  however,  distinctly  feel  the  enlarged  or  prolapsed  ovary. 
It  lies  more  laterally  and  backward,  and  is  of  oval  shape,  while  the 
swollen  tube  is  sausage-shaped  and  lies  nearer  the  edge  of  the  uterus. 
The  ovaries,  or  at  least  one  of  them  (p.  120),  swell  regularly  before 
each  menstrual  period,  and  decrease  after  menstruation.  The  tender- 
ness of  the  inflamed  ovary  is  greater  than  that  of  any  other  part  of 
the  pelvis.  The  pain  usually  gets  worse  at  the  approach  of  the  menses. 
How  the  examination  should  be  made  in  difficult  cases  is  described 
on  p.  531. 

Prognosis. — Chronic  oophoritis  rarely  leads  to  death,  although  it 
may  do  so  when  an  abscess  forms  and  ruptures.  On  the  other  hand, 
it  rarely  ends  in  perfect  recovery.  It  is  at  best  a  very  tedious  dis- 
ease, causing  much  pain  for  months  or  years,  and  it  may  even  affect 
the  mental  condition,  making  the  patient  irritable,  despondent,  hys- 
terical, epileptic,  and  weak-minded.  It  often  entails  sterility. 

Treatment. — The  treatment  coincides  in  most  respects  with  that  for 
chronic  salpingitis  (p.  532).  The  patient  should  abstain  as  much  as 
possible  from  sexual  intercourse,  and  stay  in  bed  during  menstrua- 
tion. A  depletion  and  much  relief  from  pain  are  obtained  by  giving 
hot  vaginal  douches  (p.  171),  painting  the  vaginal  vault  \vith  iodine 
(p.  170),  and  applying  cotton  tampons  with  ichthyol  glycerin  (p.  178). 
If  this  does  not  effect  a  cure,  the  galvanic  current  should  be  tried. 
I  use  it,  as  a  rule,  in  the  vagina  (p.  232),  and  make  the  current 
as  strong  as  the  patient  can  stand,  which  in  most  cases  is  up  to 


DISEASES  OF  THE  OVARIES.  563 

50  milliamperes.  Often  scarification  of  the  cervix  (p.  186),  or  the 
application  of  a  fly-blister,  2  to  4  square  inches  in  size,  every  evening, 
to  the  iliac  region,  has  a  good  effect.  Massage  (p.  190)  has  been 
much  praised,  and  may  undoubtedly  do  good  by  causing  absorption 
of  perioophoritic  adhesions  that  compress  or  pull  on  the  ovary.  But 
if  the  ovarian  inflammation  is  combined  with  pyo-  or  hematosalpinx, 
there  would  be  the  danger  of  pressing  the  contents  of  the  tubes  into 
the  peritoneal  cavity. 

The  medicinal  treatment  should  above  all  consist  in  the  administra- 
tion of  tonics  (p.  225).  The  nervous  troubles  are  often  greatly  bene- 
fited by  the  use  of  bromides.  Chloride  of  gold  has  frequently  seemed 
to  me  to  reduce  the  size  of  the  swollen  ovary  (p.  227).  Rubbing 
with  chloroform  oil  (p.  226)  affords  temporary  relief  from  pain.  A 
warm  entire  bath  should  be  taken  twice  a  week.  For  those  who  can 
travel  a  treatment  with  the  strong  iodine  brine  of  Kreuznach  or  the 
iron  mud  of  Franzensbad,  Marienbad,  or  Schwalbach,  combined  with 
the  effects  resulting  from  the  change  of  air,  new  impressions,  and 
the  interruption  of  marital  relations,  is  often  followed  by  decided 
improvement. 

This  palliative  treatment,  carried  out  methodically  and  patiently, 
is  of  great  value,  but  in  some  few  cases  nothing  short  of  an  operation 
will  cure  the  patient.  Even  when  laparotomy  or  colpotomy  is  per- 
formed, the  ovaries  need  not  always  be  removed.  If  the  tubes  are  in 
a  fair  condition,  the  ovaries  may  be  incised,  diseased  parts  cut  away, 
cysts  enucleated,  and  the  wound  closed  again  with  a  continuous  suture 
of  catgut.  If  the  ovaries  are  prolapsed,  they  may  be  lifted  up  and 
fastened  in  a  better  position  by  stitching  the  round  ligaments  to  the 
anterior  abdominal  wall.1 

But  if  the  ovaries  are  much  diseased,  and  if  the  tubes  are  in  a  bad 
condition,  the  appendages  should  be  removed  on  one  or  both  sides 
(p.  534). 

Appendix. — Gyroma  and  Endothelloma. — It  is  a  peculiarity  of  the 
ovary  that,  examined  microscopically,  it  shows  so  many  variations 
that  hardly  two  ovaries  are  alike,  and  it  is,  therefore,  difficult  to  decide 
what  is  a  normal  structure  and  what  represents  an  abnormal  process. 
(See  p.  72,  foot-note.) 

Two  conditions  have  been  described  as  diseases  under  the  names 
of  gyroma  and  endothelioma,2  which  are  intimately  connected  with 

1  Polk,  Amer.  Jour.  Obst.,  Sept.,  1891 ;  Trans.  Amer.  Gyn.  Soc.,  1893,  vol.  xviii. 
p.  175. 

*  M.  A.  Dixon  Jones,  "  A  Hitherto  Undescribed  Disease  of  the  Ovary,  Endothe- 
lioma  changing  to  Angioma  and  Hematoma,"  N.  Y.  Med.  Jour.,  Sept.  28,  1889, 
and  "  Another  Hitherto  Undescribed  Disease  of  the  Ovaries,  Anomalous  Menstrual 
Bodies  "  (Gyroma),  ibid.,  May  10  and  1 7, 1 890.  Compare  foot-note  on  p.  72.  Gyroma 
is,  however,  doubtless  the  same  that  has  been  described  by  Patenko  under  the  name 
of  corpus  fibrosum  in  Virchovfs  Archiv,  vol.  Ixxxiv.  p.  193. 


564  DISEASES  OF  WOMEN. 

each  other,  and  one  of  which,  endothelioma,  under  some  circum- 
stances, is  a  normal  development. 

Gyromas  (Fig.  286)  are  convoluted,  highly  refracting  masses,  which 
in  many  instances  replace  most  of  the  ovarian  tissue.  They  are  found 
both  in  the  cortex  and  in  the  medulla  (p.  67).  In  the  former  locality 
they  are  transformed  corpora  lutea — abnormal  menstrual  bodies — or 
corpora  lutea  of  pregnancy  (p.  71) ;  in  the  latter  they  arise  from 

FIG.  286. 


€- 


Ovary  containing  Corpus  Luteum  changed  into  Gyroma :  a,  cut  surface  of  ovary ;  6,  tube ; 

c,  c,  gyroma.1 

arteries  which  become  obliterated  by  endarteritis.  The  convolu- 
tions of  gyromas  are  in  the  former  case  due  to  the  convoluted  figure 
of  the  structureless  membrane  of  the  follicular  wall  after  it  has 
ruptured  ;  in  the  latter  they  arise  from  the  tortuous  course  of  the 
arteries  (Fig.  287). 

Those  that  are  developed  from  the  corpora  lutea  are  due  to  a  trans- 
formation of  the  medullary  corpuscles  which  are  found  outside  and 
inside  of  the  ruptured  Graafian  follicle  (p.  72,  foot-note).  Instead 
of  being  absorbed  or  transformed  into  connective  tissue,  these  med- 
ullary corpuscles  become  infiltrated  with  an  elastic  or  colloid  sub- 
stance. 

In  the  vicinity  of  a  gyroma  the  blood-vessels  are  in  an  abnor- 
mal condition  :  the  capillaries  are  large  and  straight,  the  veins  di- 
lated, and  the  arteries  not  infrequently  suffering  from  obliterating 
endarteritis  and  waxy  degeneration.  Gyromas  are  not  found  iu 
the  cow,  pig,  or  sheep,  and  are  probably  always  a  pathological  pro- 
duction.2 

1  Specimen  from  my  salpingo-oophorectomy  on  Mrs.  M ,  in  St.  Mark's  Hos- 
pital, on  Dec.  14,  1889. 

2  Dr.  Dixon  Jones  thinks  that  what  has  been  described  as  corpora  lutea  vera  or 


DISEASES  OF  THE  OVARIES. 


565 


Gyroma  is  found  in  all  cases  of  endothelioma,  but  may  also  be 
found  independently  of  the  latter.     Clinically  gyroma  is  character- 


FIG.  287. 


Gyroma  X  100  (Fr.  Foerster):  GG,  gyroma  traversed  by  delicate  tracts  of  fibrous  connective 
tissue:  CC,  newly-formed  inflamed  fibrous  connective  tissue;  AA,  arteries  with  slight 
sclerosis  and  hyaline  degeneration  ;  V.  vein  in  transverse  section ;  B,  capillaries. 

ized  by  pain  in  the  ovarian  region,  exhaustion,  and  marked  nervous 
disturbances,  which  last  may  proceed  so  far  as  hysteria  and  mental 
aberration. 

Endothelioma  (Fig.  288)  is  always  an  outcome  of  ovulation,  a 
growth  of  the  structureless  membrane  of  the  follicular  wall  (p.  69). 
Similar  formations  are  found  in  the  pregnant  cow,  pig,  and  sheep. 
Some  endotheliomas  are,  indeed,  nothing  but  corpora  lutea  of  preg- 
nancy, but  others  are  transformed  gyromas,  which,  as  we  have  seen, 
are  always  a  pathological  product.  While  gyromas  may  be  found 
in  an  ovary  in  varying  numbers,  endothelioma  is  invariably  single. 

It  is  composed  of  large  alveoli,  or  closed  spaces,  filled  with  endo- 

corpora  lutea  of  pregnancy  (p.  71)  is  nothing  else  but  anomalous  menstrual  bodies, 
gyromas  and  endotheliomas  changing  into  angiomas  and  hematomas  ( "  Another 
Hitherto  Undescribed  Disease,"  reprint,  p.  24) — a  rather  startling  supposition  (see 
p.  72). 


566 


DISEASES  OF  WOMEN. 


thelial  cells.  The  wall  of  the  alveoli  consists  of  coarse  fibrous  con- 
nective tissue,  richly  supplied  with  blood-vessels.  The  endothelial 
cells  are  globular,  fusiform,  or  polyhedral  corpuscles,  mainly  arranged 


FIG.  288. 


Endothelioma  of  Ovary  (Jones):  C,  coarse  connective  tissue  containing  V,  large  blood-vessels, 
mainly  venous  in  character;  S,  septum  or  prolongation  of  connective  tissue  into  a  closed 
space  filled  with  globular  and  angular  corpuscles  in  rows ;  between  the  rows  there  are 
fat-globules  and  empty  slits ;  A,  cellular  elements. 

in  rows  and  intermixed  with  dark  brown  fat-globules  and  pigment- 
granules. 

The  rows  are  in  many  places  interrupted  by  light  gaps,  probably 
caused  by  liquefaction  of  some  of  these  cells. 

In  the  vicinity  of  an  endothelioma  there  are  large  varicose  veins 
and  often  aneurismatic  arteries,  which  occasionally  rupture,  and  cause 
hemorrhage  under  the  albuginea  or  into  adjacent  cysts. 

Sometimes  some  of  the  cells  are  transformed  into  red  blood-cor- 
puscles, while  others  fuse  together,  forming  vessels  around  the  new- 
formed  blood.  (See  Hematoma,  p.  556.)  The  endothelial  growth 
replaces  gradually  the  normal  ovarian  tissue,  and  may  occupy  the  whole 


DISEASES  OF  THE  OVARIES.  567 

ovary,  which,  however,  is  not  much  increased  in  size,  and  sometimes 
even  smaller  than  normal.  The  ova  are  diseased  or  destroyed. 

The  clinical  features  of  endothelioma  are  lancinating  pain  in  the 
region  of  the  ovary,  progressive  emaciation,  pronounced  pallor,  and 
great  weakness. 

By  destroying  the  patient's  health  and  rendering  her  sterile  the 
affection  is  of  great  importance. 

Both  gyroma  and  endothelioma  originate  in  chronic  oophoritis,  and, 
again,  they  cause  inflammation  in  the  surrounding  tissue.  Some  path- 
ologists  take  endothelioma  to  be  a  variety  of  carcinoma,  which  fits 
well  with  the  clinical  aspect. 

As  the  presence  of  these  conditions  can  only  be  proved  by  micro- 
scopical examination,  they  cannot  be  a  guide  in  regard  to  treatment, 
but  when,  after  oophorectomy,  they  are  found  in  the  removed  ovaries, 
they  bear  witness  to  the  justifiableness  of  performing  the  operation. 


CHAPTER   V. 

NEOPLASMS. 

THE  ovaries  are  very  frequently  the  seat  of  neoplasms.  Some  are 
cystic,  others  are  solid. 

A.   Cysts. 

Pathological  Anatomy. — Ovarian  cysts  offer  a  great  variety  in  their 
anatomical  structure,  but  they  may,  nevertheless,  be  reduced  to  a  few 
types : 

I.  Dropsy  of  the  Graafian  follicle  (hydrops  folliculi),  assuming  one 
of  three  forms :  1,  a  conglomeration  of  many  small  cysts  in  the  interior 
of  the  ovary ;  2,  a  similar  formation,  but  with  pedunculated  cysts,  by 
which  the  whole  ovary  may  become  like  a  bunch  of  grapes  (Roki- 
tanski's  tumor") ;  and  3,  the  development  of  a  few  or  one  large  cyst ; 
II.  Proliferating  cysts,  occurring  in  three  varieties:  1,  glandular, 
2, papillary,  and  3,  mixed:  III.  dermoid  cysts;  and,  IV.  tubo-ova- 
rian  cysts.1 

1  While  the  author  was  collecting  materials  for  his  work  on  Diagnosis  of  Omrian 
Oysts  by  means  af  the  Examination  of  their  Contents,  he  had  the  advantages  of  wit- 
nessing all  the  ovariotomies  performed  in  the  Woman's  Hospital  in  the  State  of 
New  York  during  eighteen  months,  and  of  obtaining  a  part  of  the  fluid  and  the  sac 
and  the  ovary  of  the  opposite  side  when  it  was  diseased.  Not  only  was  the  fluid 
examined  chemically  and  microscopically  in  every  case,  but  many  hundreds  of 
specimens  were  cut  from  the  hardened  sacs  or  small  ovaries.  In  that  work  he  refers 
also  in  many  places  to  the  solid  part  of  ovarian  cysts,  and  if  other  occupations  have 
prevented  him  from  increasing  the  material  and  utilizing  it  for  a  special  essay,  his 
personal  acquaintance  with  all  stages  of  cystic  degeneration  of  ovaries  has  enabled 
him  to  better  understand  and  value  the  work  of  other  investigators  in  this  domain. 


568 


DISEASES  OF  WOMEN. 


I.     Dropsical  Graafom  Follides. 


In  studying  chronic  oophoritis  we  have  seen  (p.  559)  that  often  in 
that  disease  many  small  follicles  may  be  transformed  into  cysts,  and 


FIG.  289. 


Ovary  with  many  Dropsical  Follicles  (Leopold). 

that  a  single  follicular  cyst  may  cause  the  absorption  of  the  rest  of 
the  ovary.      Thus  there  is  #  gradual  transition  from  oophoritis,  an 


FIG.  290. 


Bilateral  Oligocystic  Ovarian  Tumors  (Hooper). 


in 


inflammatory  disease,  to  cystic  degeneration,  a  neoplasm,  and  it  is 
reality,  in  some  cases,  only  the  size  of  the  specimen  which  decides  us  in 
calling  the  disease  by  one  or  the  other  name.  The  proof  that  a  cyst 
is  of  follicular  origin  is  the  presence  of  the  ovum ;  and  by  the  con- 
formity of  the  structure  and  the  fluid  we  are  led  to  regard  larger  cysts, 


DISEASES  OF  THE  OVARIES.  569 

even  when    the    ovum  has   disappeared,   as  being   developed   from 
follicles. 

If  many  follicles  are  affected  simultaneously  (Fig.  289),  the  ovary 
does  not  obtain  very  large  dimensions,  indeed  hardly  more  than  the 
size  of  an  hen's  egg.  The  stroma  may  be  unchanged  or  infiltrated 
with  medullary  elements.  Gradually  it  is  absorbed. 

FIG.  291. 


Rokitanski's  Tumor,  one-third  actual  size  (Tait) ;  on  the  right  is  seen  the  adherent  omentum. 

Sometimes  a  few  follicles  become  cystic,  forming  what  is  called  an 
oligocystic  tumor  (Fig.  290).     Very  rarely  the  partition  between  two 


570 


DISEASES  OF   WOMEN. 


such  cysts  ruptures,  so  that  they  communicate.  As  a  rule,  only  one 
is  developed ;  or,  predominating  in  its  development,  causes  the  atrophy 
and  disappearance  of  the  others. 

If  only  one  follicle  undergoes  cystic  degeneration,  it  may  form  a 
tumor  of  the  size  of  a  man's  head  or  even  a  uterus  at  term.1 

Such  a  large  cyst  is  strictly  monocystic.  Nowhere  are  found  rem- 
nants of  partitions.  The  wall  is  white,  and  consists  of  two  layers  of 
dense  fibrous  connective  tissue  held  together  with  a  layer  of  loose 
connective  tissue,  in  which  run  blood-vessels.  The  arteries  are  thick- 
ened in  consequence  of  endarteritis.  These  two  layers  correspond 
probably  to  the  tunica  propria  and  the  combined  tunica  fibrosa  and 
albuginea  (p.  68).  The  outside  is  covered  with  a  short  columnar 
epithelium ;  the  inside  has  a  similar  epithelium  with  somewhat  longer 
cells. 

The  fluid  is  serous,  alkaline,  and  almost  colorless.  It  does  not  coag- 
ulate spontaneously  nor  by  heat.  It  contains  paralbumin,  the  presence 

FIG.  292. 


Ovaries  with  Pedunculated  cysts  (Wiiikel) :  a,  anterior  wall  of  uterus  cut  open,  showing  a 
primary  sarcoma  of  the  body;  6, c,  ovaries  with  multiple  pedunculate  cysts;  d,e,  tubes ; 
/,  posterior  wall  of  bladder. 

of  which  is  characterized  by  its  precipitation  when  the  fluid  is  boiled 
with  a  small  amount  of  acetic  acid,  the  precipitate  being  redissolved 
by  adding  an  excess  of  the  same  reagent.  It  contains  only  a  few 
granules  and  no  cellular  elements. 

These  mouocystic  and  oligocystic  tumors  are  much  rarer  than  the 
proliferating  and  dermoid  cysts. 

Rokitanski's  Tumor  (Fig.  291). — Much  rarer  still  is  that  species 

1  I  have  seen  it  contain  a  pailful  of  fluid  (Diagnosis,  p.  9). 


DISEASES  OF  THE  OVARIES. 


571 


of  ovarian  cystic  tumor  which  from  the  name  of  the  man  who  first 
described  it  is  called  Rokitanski's  tumor.  In  fact,  only  a  few  cases 
are  known.  This  seems  always  to  be  a  bilateral  affection.  The 
tumors  grow  slowly.  They  are  of  moderate  size,  between  that  of  the 
fist  of  a  man  and  that  of  the  head  of  a  four-year  old  child.  They  are 
composed  of  innumerable  cysts  varying  from  the  minutest  size  to  that 
of  an  orange.  The  wall  is  thin  and  lined  with  columnar  epithelium  ; 
the  contents  are  limpid ;  and  the  ovum  is  nearly  always  found  in 
every  cyst. 

The  cysts  may  become  more  or  less  pedunculated,  so  as  to  impart 
to  the  whole  tumor  the  appearance  of  a  bunch  of  grapes. 

FIG.  293.  A. 


FIG.  293.  B. 


A.  Inner  Surface  of  Glandular  Ovarian  Cystoma  (partly  diagrammatic)  x  120:  a,  connective 

tissue;  b, epithelium  ;  c, bowl-shaped  depression  witli  small  opening ;  d,  a  similar  one, the 
opening  closing  up;  ej,  buds  of  epithelium,  growing  from  the  bottom  of  the  bowl ;  gg. 
depressions  in  the  connective  tissue,  from  which  the  epithelium  has  been  removed. 

B.  Same  as  c  in  Fig.  276  A,  enlarged  360  times.    It  is  composed  of  two  pouches  uniting:  at  the 

top.  The  centre  of  each  is  undergoing  liquefaction.  A  kind  of  thready  material  is  seen 
extending  from  the  periphery  into  the  interior  of  the  pouch  between  the  epithelial  cells 
(cement  substance). 


Fig.  292  shows  the  ovaries  with  a  few  pedunculated  cysts  on  the 
surface. 

II.  Proliferating  Cysts. — Proliferating  cysts  are  also  called  myxoid 
cystomas,  in  opposition  to  the  dermoid  cystomas,  because  their  inner 
surface  resembles  a  mucous  membrane.  The  epithet  "proliferating" 


572 


DISEASES  OF  WOMEN. 


has  been  given  them  because  they,  differing  entirely  from  the  above- 
described  large  cysts  due  to  dropsy  of  the  follicle,  which  are  strictly 
monocystic  with  a  smooth  inner  surface,  produce  new  cysts  or  papil- 
lary growths  from  their  inner  surface.  With  regard  to  these  two 
different  kinds  of  proliferations  the  myxoid  cystomas  are  again  sub- 
divided into  two  groups — glandular  myxoid  cystoma  and  papillary 
myxoid  cystoma. 

a.  Glandular  ovarian  cysts  have  a  wall  composed  of  the  same  two 
layers  we  found  in  the  case  of  follicular  dropsy,  and  a  similar  external 
epithelium,  but  the  internal  epithelium  undergoes  a  remarkable  pro- 
liferation, which  results  in  the  development  of  gland-like  growths. 
This  epithelium  is  polymorphous ;  that  is  to  say,  different  forms 
of  cells — columnar,  goblet-shaped,  and  flat — are  found  in  it,  but  the 
long  columnar  is  the  predominating  variety.  It  is  stratified  and 
forms  pouches,  which  at  first  are  placed  regularly  side  by  side, 
and  are  of  about  the  same  size  (Fig.  293);  but  in  consequence 
of  the  continued  proliferation  of  the  epithelial  cells  some  of  these 
pouches  become  closed,  thus  forming  a  secondary  cyst  in  the  wall 
of  the  primary  cyst.  At  first,  it  is  a  nearly  solid  mass  of  epithe- 
lial cells,  but  soon  the  cell-body  begins  to  melt,  setting  the  nucleus 
free  (Fig.  294),  and  forming  a  fluid  in  the  secondary  cyst.  This 


.FIG.  294. 


Melting  of  Epithelial  Cells  in  Secondary  Cyst  in  the  Wall  of  an  Ovarian  Cyst. 

process  can  be  followed  under  the  microscope,  and,  by  analogy,  we 
may  infer  that  the  same  takes  place  in  the  primary  cyst.  When 
the  secondary  cyst  is  formed,  the  same  process  of  proliferation  is 
repeated,  so  that  continually  one  generation  of  cysts  is  formed  in 
the  wall  of  another. 

Simultaneously  with  this  production  of  new  cavities  a  reduction  in 
their  number  takes  place  by  the  absorption  of  the  partition  which 
separates  two  cysts  from  one  another.  At  first  there  is  only  a  small 
hole  of  communication  between  the  two  sacs,  but  gradually  the  open- 


DISEASES  OF  THE  OVARIES. 
FIG.  295. 


573 


Small  Glandular  Ovarian  Cyst,  with  beginning  absorption  of  partition.    Slightly  reduced 
from  natural  size  (Doran). 

FIG.  296. 


Large  Glandular  Ovarian  Cyst,  showing  numerous  secondary  cysts  and  ridges  as  remnants 
of  absorbed  partitions:  a,  primary  cyst  turned  inside  out  and  stuffed  with  cotton;  66, 
secondary  cysts ;  cc,  remnants  of  absorbed  partitions.1 

-,  at  St.  Mark's  Hospital, 


1  Specimen  from  my  ovariotomy  on  Mrs.  M.  S- 
Aug.  14,  1890.     It  contained  sixteen  quarts  of  fluid. 


574 


DISEASES  OF  WOMEN. 


ing  increases  in  size  until,  finally,  only  a  low  ridge  remains  as  a  rem- 
nant of  the  former  partition  (Figs.  295  and  296). 

By  this  continual  proliferation  of  epithelial  cells,  formation  of  new 
cysts,  and  absorption  of  partitions  very  large  tumors  are  formed,  in 
which,  as  a  rule,  one  cyst  predominates,  but  there  are  invariably  found 
a  greater  or  smaller  number  of  secondary  cysts  in  its  wall.  These 
cysts  are,  therefore,  always  multilocular  from  a  pathological  standpoint, 
even  if  from  a  surgical  they  may  be  regarded  as  unilocular. 

The  healthy  ovarian  tissue  disappears  entirely  as  soon  as  the  tumor 
reaches  a  few  inches  in  diameter. 

The  glandular  variety  is  by  far  the  most  common,  and  forms  the 
largest  tumors  of  all.  Their  growth  may,  indeed,  become  so  enor- 
mous that  they  weigh  more  than  the  rest  of  the  body  (Fig.  297).1 

FIG.  297. 


Enormous  Glandular  Ovarian  Cystoma  (Rodenstein). 

Fig.  298,  on  the  other  hand,  represents  such  a  glandular  cystoma 
found  in  a  new-born  child,  and  enlarged  thirty  times. 

The  outer  layer  of  the  wall  corresponds  to  the  albuginea,  is  smooth, 
of  dense  texture,  a  pearl-gray  or  white  color,  and  takes  no  part  in  the 
formation  of  secondary  cysts,  which  exclusively  takes  place  in  the 
inner  layer. 

The  inner  layer  furnishes  the  connective  tissue  which,  together  with 
the  inner  epithelium,  enters  into  the  composition  of  the  secondary  cysts. 
It  is  -of  a  reddish  color,  slightly  uneven,  and  velvety  like  the  inside 

1  The  figure  represents  the  patient  after  death  at  the  age  of  forty-five  years.  The 
tumor  stood  three  feet  high,  covered  the  breasts,  went  down  to  the  knees,  and  weighed 
146  pounds  (Dr.  L.  A.  Rodenstein,  Amer.  Jour.  Obst.,  1879,  vol.  xii.  p.  315). 


DISEASES  OF  THE  OVARIES. 


575 


of  the  stomach.  Often  it  is  brown  from  impregnation  with  extrava- 
sated  blood,  or  yellow  in  consequence  of  fatty  degeneration.  Some- 
times it  has  hard  spots,  due  to  calcareous  infiltration. 


FIG.  298. 


Congenital  Multilocular  Cystoma,  X  30  (Winckel). 


From  the  outer  layer  may  grow  small  excrescences,  covered  with 
the  common  short  columnar  epithelium  (Fig.  299). 


FIG.  299. 


Papilloraatous  Excrescence  on  Outer  Surface  of  Myxoid  Proliferating  Glandular  Cystoma  of 
Ovary  (natural  size):  A,  seen  from  above;  B,  sagittal  section  of  tbe  same,  with  part  of 
cyst-wall,  showing  that  the  papilloma  was  only  connected  with  the  outer  part  of  the 
wall,  and  did  not  spring  from  the  interior  of  the  cyst :  a,  papilloma,  sagittal  section 
through  pedicle;  6,  main  cyst;  c,  secondary  cyst,  partially  filled  with  cheesy  contents, 
partially;  empty ;  d,  secondary  cyst  with  cheesy  contents. 

In  the  loose  connective  tissue  between  the  two  layers  of  the  wall 
are  found  plain  muscular  fibers,  especially  near  the  ligament  of  the 
ovary.  Sometimes  cysts  have  been  found  there,  and  even  a  corpus 
luteum. 

The  glandular  cystoma  has,  as  a  rule,  a  pedicle. 

Relation  to  Cancer. — Being  a  neoplasm  chiefly  composed  of  epi- 


576  DISEASES  OF  WOMEN. 

thelial  cells  and  a  stroma  of  connective  tissue,  the  glandular  cystoma 
approaches  the  structure  of  carcinoma.  The  difference  is  that  glandu- 
lar cystoma  does  not  affect  the  lymphatic  system,  does  not  give  rise 
to  relapse  after  extirpation,  and  has  the  tendency  to  produce  more  or 
less  fluid  in  its  compartments.  If,  however,  the  epithelial  prolifera- 
tion predominates  much,  and  the  formation  of  cysts  stops,  the  condi- 
tion is  passing  into  that  of  carcinoma.  The  appearance  in  the  wall 
of  epithelial  cells  of  much  larger  size  than  those  commonly  found  in 
the  wall  of  ovarian  cysts  is  likewise  characteristic  of  beginning  car- 
cinoma. 

Contents  of  Glandular  Cysts. — In  microscopical  new-formed  cysts 
nearly  the  whole  body  is  one  solid  mass  of  epithelial  cells.  As  a 
rule,  the  contents  become  more  fluid  as  the  cyst  grows,  but  there  are 
tumors  called  parviloeular,  in  which  each  compartment  never  reaches 
any  considerable  size.  The  whole  tumor  is  like  a  honeycomb,  and 
the  contents  never  become  more  fluid  than  a  thick  gelatinous  mass, 
in  which  even  the  microscope  fails  to  find  any  structure. 

The  fluid  in  common  ovarian  cysts  is  of  a  gray,  yellow,  or  brown 
color.  It  may  be  limpid  as  spring- water,  or  so  filled  with  solid  bodies 
as  not  even  to  be  translucent.  Usually  it  is  more  or  less  viscid.  The 
specific  gravity  of  the  specimens  examined  by  me  varied  from  1013 
to  1062.  Its  reaction  is  alkaline.  As  a  rule,  it  does  not  foam  much, 
if  at  all,  on  being  withdrawn  from  the  cyst. 

Generally  ovarian  fluid  does  not  coagulate  sponta- 
• IG*  neously ;  but  by  being  boiled,  as  a  rule,  the  contents 

0      ®        are  more  or  less  completely  turned  into  a  solid  mass. 
*©r  ^b        Ovarian  fluid  possesses  a  remarkable  degree  of  resist- 
ance to  decomposition  :  while  in  ascitic  fluid  all  form- 
^  elements  are  destroyed  within  a  few  days,  in  ovarian 

fluid  they  are  sometimes  preserved  for  weeks  or  months, 
gfe      ,„  The  fluid  contains  nearly  always  paralbumin. 

&  As  a  rule,  ovarian  fluid  is  full  of  a  variety  of  form- 

elements  :  red  blood-corpuscles,  epithelial  cells  (either 
'     ®     intact  or  metamorphosed),   nuclei,  pigment-granules, 
«J  O   O         finely  granular  globular  bodies  like  lymph-corpuscles 
Red  Biood-cor-      or  colorless  blood-corpuscles,  pus-corpuscles,  spindle- 
shaped  cells,  crystals  of  cholesterin  and  of  indican. 
Figures  300-313  show  most  of  these  bodies.     A  few  remarks  about 
them  will  suffice. 

Besides  the  well-known  common  shape  of  red  blood-corpuscles  we 
find  crenated,  rosette-shaped,  thorn-apple-shaped,  and  hematoblasts 
(Fig.  300). 

Epithelial  cells  (Fig.  301)  are  almost  constantly  found.  They  are 
columnar  seen  in  side  view,  and  multangular  in  front  view.  All  show 
signs  of  fatty  degeneration.  When  this  process  reaches  a  high  degree, 


DISEASES  OF  THE  OVARIES. 
FIG.  301. 


577 


Epithelial  Cells,  single  and  grouped,  in  front  and  side  view. 

the  epithelial  cells  appear  as  so-called  gorged  corpuscles,  or  Bennett's 
large  corpuscles  (Fig.  302).     Often  vacuoles  are  formed  in  epithelial 


FIG.  302. 


Bennett's  Large  Corpuscles,  or  Nunn's  Gorged  Corpuscles — i.  e.  epithelial  cells  in  fatty 

degeneration,  • 

cells,  which   probably  are  a  kind  of  disintegration  leading  to  the 
destruction  of  the  cells. 

FIG.  303. 


Colloid  Corpuscles. 


578 


DISEASES  OF  WOMEN. 


Colloid  corpuscles  (Fig.  303),  large  and  small,  are  probably  either 
parts  detached  from  epithelial  cells  or  a  transformation  of  the  whole 
cells. 

FIG.  304.  FIG.  305. 


Horn-cells. 


Proliferating  Cells. 

Horn-cells  (Fig.  304)  are  epithelial  cells  that  have  lost  their  proto- 
plasm, have  sharp  ridges,  and  look  horny. 

FIG.  306.  FIG.  307. 


Ameboid  Bodies. 


A  Large  Bennett  Cor- 
puscle with  ame- 
boid movements. 


Proliferating  cells  (Fig.  305)  are  large  cells  containing  a  brood  of 
younger  ones  in  their  interior,  from  which  they  escape  to  lead  an  inde- 
pendent existence. 

FIG.  308. 


Bennett's  Small  Corpuscles,  or  Drysdale's  Corpuscles— i.  e.  nuclei  in  fatty  degeneration. 
FIG.  309.  FIG.  310. 


Cells  with  nucleus  and  fine  dark  granules 
(enlarged  colorless  blood-corpuscles?) 


Flakes  of  epithelium,  the  cells  melt- 
ing and  setting  the  nucleus  free. 


In  quite  fresh  fluid  it  is  not  rare  to  find  cells  with  ameboid  move- 
ments. In  Fig.  306  we  see  the  same  two  cells  in  three  different 
stages  of  separation  and  amalgamation. 


DISEASES  OF  THE  OVARIES. 
FIG.  312. 


579 


FIG.  311. 


Fat-granules. 


Spindle-cells  from  a  myxofibromatous  ovarian  cyst. 


Drysdale's  corpuscles  (Fig.  308)  are  small  globular  or  polyhedral 
clear  bodies  with  a  small  number  of  shining  granules.     My  inves- 


Fio.  313. 


Cholesterin. 


tigations  have  led  me  to  believe  that  these  bodies  are  nuclei  of  epi- 
thilial  cells  in  fatty  degeneration  (Fig.  310). 

Ovarian  fluid  contains  also  round  cells  with  a  nucleus  and  finely 


Papillary  Ovarian  Cyst  springing  from  the  hilum  of  the  ovary,  the  greater  part  of  which  is 
not  involved  in  the  morbid  growth.  The  cyst  has  forced  its  way  between  the  layers  of 
the  broad  ligament  as  far  as  the  Fallopian  tube  (Doran). 


granular  protoplasm  (Fig.  309),  the  nature  of  which  is  uncertain. 
Perhaps  they  are  enlarged  colorless  blood-corpuscles. 


580 


DISEASES  OF  WOMEN. 


b.  Papillary  Ovarian  Cysts  are  by  far  not  so  common  as  glandular, 
being  found  in  only  one  out  of  ten  ovariotomies,  and  do  not  acquire  so 
large  proportions.  They  contain  a  comparatively  small  number  of  sec- 
ondary cysts.  From  their  inside  spring  dendritic  or  cauliflower-shaped 
growths,  called  papillomas  (Fig.  314),  which  may  fill  the  secondary 
cyst  in  which  they  grow,  and  break  through  its  wall  into  a  neighbor- 
ing cyst,  or  perforate  the  wall  of  the  primary  cyst,  so  as  to  come  to 
lie  in  the  peritoneal  cavity,  where  they  may  cover  the  outside  of  the 
ovary  and  neighboring  parts. 

They  may  even  penetrate  the  uterus,  the  bladder,  the  rectum  or 
other  viscera,  so  as  to  form  one  mass  with  them.  The  ends  of  papillo- 
matous  growths  may  also  coalesce  in  the  interior  of  the  cyst,  thus 
forming  a  separate  compartment  or  secondary  cyst. 

The  papillae  range  in  size  from  that  of  a  pea  to  that  of  a  small 
orange.  They  are  sessile  or  pedunculated,  white,  dark  red,  or  black. 

The  inside  of  papillary  cysts  is  usually  lined  with  a  ciliated  epithe- 
lium, and  the  fluid  in  their  interior  is  not  viscid  or  colloid,  but  more 
watery. 

This  kind  of  tumors  is  often  bilateral,  and  develops  in  a  consider- 


FIG.  315. 


pmt 


Superficial  Papillomata  on  both  ovaries  (Coblenz) :  RO,  right  ovary ;  LO,  left  ovary  ;  /«,  fun- 
das  uteri ;  nc,  hyaline  cyst ;  pv,  papillary  vegetations ;  cy,  cystic  tumors ;  bg,  blood-vessels ; 
km,  hydatid  of  Morgagni ;  old,  abdominal  orifice  of  right  tube :  ots,  abdominal  orifice  of 
left  tube ;  lee,  calcareous  deposits;  11, broad  ligament;  Ir,  round  ligament ;  at';  infundibulo- 
pelvic  ligament;  ut,  uterus;  pru,  vaginal  portion  of  uterus;  vw,  vaginal  wall  laid  open. 

able  number  of  cases  between  the  folds  of  the  broad  ligaments.     The 
development  is  much  slower  than  that  of  the  glandular  variety.     It 


DISEASES  OF  THE  OVARIES.  581 

is  often  accompanied  by  ascites,  and,  if  removed  by  tapping,  the  fluid 
reaccumulates  in  a  short  time. 

It  is  not  rare  to  find  grains  of  a  sand-like  substance  in  the  papillo- 
matous  masses,  so-called  corpora  arenacea,  or  sand-bodies,  like  those 
forming  in  the  brain  the  tumor  called  a  psammoma. 

In  this  variety  normal  ovarian  tissue  is  preserved  longer  than  in 
the  glandular. 

Superficial  Papillomata. — Papillomata  on  the  outside  of  an  ovary 
are  not  always  due  to  rupture  of  a  papillomatous  cyst.  They  may 
also  develop  originally  on  the  surface  (Fig.  315). 

c.  Mixed  Proliferating  Ovarian  Cysts. — In  one  and  the  same  cys- 
toma  some  cavities  may  be  of  the  glandular  type,  others  of  the  papil- 
lary. Thus  there  seems  not  to  be  any  radical  difference  between  the 

FIG.  316. 


Portion  of  the  Wall  of  a  Dermoid  Ovarian  Cyst  (Ziegler) :  a,  wall ;  6,  elevation  composed  of 
of  fatty  and  cutaneous  tissues ;  c,  hairs  ;  d,  teeth. 

two  varieties — a  point  to  which  we  shall  come  back  in  speaking  of  the 
origin  of  ovarian  cysts.  From  the  history  of  the  development  of  the 
ovaries  (p.  26)  we  know  that  from  a  very  early  period  these  bodies  are 
built  up  of  two  elements — epithelial  cells  and  connective  tissue. 
In  the  glandular  cystoma  the  former  predominates,  in  the  papillary 
the  latter. 

III.  Dei-moid  Cysts. — Dermoid  cysts  differ  entirely  from  all  those 


582  DISEASES  OF   WOMEN. 

hitherto  described,  both  as  to  sac  and  contents.  While  in  the  other 
kinds  of  cysts  the  inner  surface  reminds  one  of  the  mucous  membrane 
of  the  intestinal  canal,  in  the  dermoid  variety  it  is  like  skin,  not  only 
in  general  appearance,  but  in  regard  to  the  elements  that  enter  into 
its  composition  (Fig.  316).  Thus  the  inside  is  covered  with  a  thick 
layer  of  stratified  epidermal  cells,  the  most  superficial  flat  and 
without  nuclei,  the  deeper  round  or  polyhedral.  Outside  of  this  comes 
a  layer  like  derma,  then  one  of  subcutaneous  adipose  tissue,  and 
finally  a  layer  of  fibrous  connective  tissue  corresponding  to  the  outer 
layer  of  other  ovarian  cysts.  The  derma  is  often  raised  in  more  or 
less  regular  papillae.  It  may  contain  sudoriferous  glands,  with  ducts 
opening  on  the  inner  surface,  or  sebaceous  glands  opening  into  the 
sheaths  of  hairs.  Such  hairs  spring  often  from  a  small  prominence 
and  may  form  a  switch  several  feet  long,  rolled  up  into  a  ball,  and 
usually  of  a  reddish  yellow  color.  In  other  places  may  be  seen  teeth, 
often  in  large  number  (up  to  three  hundred  have  been  found  in  one 
cyst).  Sometimes  several  teeth  together  are  inserted  in  one  piece  of 
bone.  Even  a  kind  of  shedding  may  go  on,  a  tooth  with  a  decaying 
root  sitting  over  a  young  healthy  one,  just  as  in  the  mouth  the  milk- 
teeth  are  eroded  and  thrown  off  by  the  permanent  teeth. 

If  there  are  many  teeth,  the  bicuspid  form  predominates.  If  there 
are  only  few,  they  are  generally  like  the  incisors  or  canines. 

Besides  these  attributes  of  the  skin,  many  other  tissues,  or  even 
simulacra  of  organs,  have  been  found  in  the  wall  of  dermoid  cysts : 
bones  (usually  of  the  flat  type),  cartilage,  striped  and  plain  muscle- 
fibers,  gray  brain  matter,  nerves  going  to  the  teeth,  mucous  membrane 
like  that  of  the  intestine,  a  body  like  the  submaxillary  gland,  a  breast 
with  papilla,  a  metacarpus  with  articulations,  a  trachea,  a  heart  with 
mitral  valve,  columnae  carneae  and  chordae  tendinese,1  and  even  an  eye. 

The  outer  surface  of  a  dermoid  cyst  is,  as  a  rule,  of  a  dull  gray  or 
greenish  color  with  orange  or  ocherous  patches. 

Dermoid  cysts  are  small  or  of  medium  size,  rarely  exceeding  that 
of  the  head  of  an  adult. 

Commonly  only  one  ovary  is  affected,  but  the  occurrence  of  the 
disease  on  both  sides  is  not  rare. 

Two  or  three  dermoid  cysts  may  develop  in  the  same  ovary.  In 
the  course  of  time,  when  the  separate  cysts  grow,  the  partitions 
between  them  are  absorbed,  and  they  are  blended  into  one. 

A  dermoid  cyst  may  form  adhesions  and  rupture  into  another 
organ  or  on  the  surface  of  the  body.  If  it  opens  into  the  bladder, 
hairs  may  be  eliminated  with  the  urine  (pUimiction). 

Dermoid  cysts  may  give  rise  to  metastasis  in  the  shape  of  small 
yellow  nodules  on  the  peritoneum,  of  characteristic  composition. 

A  dermoid  cyst  in  one  ovary  may  be  combined  with  a  proliferating 
1  A.  W.  Johnstone,  Trans.  Amer.  Gyn.  Soc.,  1893,  vol.  xviii.  p.  305. 


DISEASES  OF  THE  OVARIES.  583 

myxoid  cystoraa  in  the  other.  In  the  same  ovary  some  compart- 
ments of  a  cyst  may  have  the  dermoid  and  others  the  myxoid  type, 
and  the  two  kinds  may  even  be  represented  in  one  and  the  same 
small  secondary  cyst. 

Contents  of  Dermoid  Cysts. — The  fluid  contained  in  dermoid  cysts 
is  characterized  by  its  richness  in  fat-globules  and  cholesterin.  It 
may  be  so  thick  that  it  hardly  can  pass  through  a  canula,  and 
solidifies  as  soon  as  it  is  exposed  to  the  air.  It  contains  often  lumps 
of  solid  fat,  and  in  a  few  cases  this  has  been  found  in  the  shape  of  a 
large  number  of  balls  of  the  same  size  and  as  round  as  billiard- 
balls. 

This  fluid  has  a  nauseating  odor.  It  does  not  give  the  reaction  of 
paralbumin.  It  contains  cholesterin,  urea,  oxalic  acid,  leucin,  tyrosin, 
and  xanthin. 

Dermoid  cysts  are  much  rarer  than  proliferating  cysts,  less  than  4 
per  cent,  of  ovarian  tumors  having  this  type. 

Before  puberty  this  is,  however,  the  predominating  variety.  Fre- 
quently its  occurrence  is  combined  with  an  imperfect  development  of 
the  genitals. 

Similar  cysts  have  been  found  in  other  parts  of  the  body,  such  as 
the  head,  the  neck,  the  sacrum,  the  pit  of  the  stomach,  the  perineum, 
the  testicle,  the  uterus,1  the  organs  of  the  chest,  and  other  abdominal 
organs,  etc. ;  but  they  are  more  frequent  in  the  ovary  than  anywhere 
else. 

IV. — Tubo-ovarian  Cysts,  or  Hydrocele  of  the  Ovary. — Tubo- 
ovarian  cysts  consist  of  a  combination  of  a  cystic  salpingitis  (p.  541) 
with  a  cyst  of  the  ovary.  They  have  the  shape  of  a  retort.  The 
line  of  demarkation  between  the  two  organs  is,  as  a  rule,  distinctly 
visible.  The  fimbria?  may  have  disappeared  altogether  or  may  be 
spread  over  the  outer  surface  of  the  ovarian  cyst ;  or  we  may  find 
them  inside,  floating  from  the  inner  surface  or  attached  to  it  from 
end  to  end. 

The  tubal  part  is  covered  with  peritoneum,  and  the  inner  surface 
has  in  the  beginning  ciliated  columnar  epithelium,  but  later  the  cilia 
disappear,  and  the  cells  may  become  flattened. 

The  uterine  opening  commonly  remains  pervious,  so  that  the  con- 
tents may  from  time  to  time,  when  pressure  increases,  be  evacuated 
through  the  vulva. 

Bland  Button 2  calls  tubo-ovarian  cysts  hydrocele  of  the  ovary,  and 
says  there  is  good  reason  to  believe  that  they  arise  in  a  tunic  of  the 
peritoneum  that  occasionally  invests  the  ovary,  much  in  the  same  way 
that  the  tunica  vaginalis  clothes  the  testis.  The  ovary  is  replaced  by 

1  W.  W.  Stewart  of  Columbus,  Ga.,  Med.  Record,  Nov.  11,  1893,  vol.  xliv.  No.  21, 
p.  648. 

2  Bland  Sutton,  Diseases  of  the  Ovaries  and  Tubes,  Philadelphia,  1891,  p.  111. 


584  DISEASES  OF  WOMEN. 

a  cyst  which  communicates  with  a  distended  tube,  but  the  orifice  of 
communication  is  an  adventitious  opening,  and  does  not  represent  the 
abdominal  ostium  of  the  tube.  What  is  usually  called  hydrops  tubae 
profluens  this  author  calls  intermitting  ovarian  hydrocele. 

As  a  rule,  the  affection  is  unilateral. 

All  kinds  of  ovarian  tumors  may  undergo  this  blending  with 
cystic  salpingitis.  All  that  has  been  said  above  about  the  size  of  the 
tumor  and  the  nature  of  the  fluid  of  ovarian  tumors  applies,  there- 
fore, to  tubo-ovarian  cysts. 

Probably  a  catarrhal  salpingitis  (p.  525)  is  a  forerunner  for  the 
formation  of  this  kind  of  cyst.  A  hydrosalpinx  (p.  544)  is  formed, 
adhesion  to  the  cystic  ovary  follows,  the  partition  becomes  atrophied, 
and  finally  the  two  cavities  form  one. 

All  ovarian  cysts  may  be  unilateral  or  bilateral.  Dermoid  cysts 
are  oftener  only  found  on  one  side ;  proliferating  papillary  cysts  and 
Rokitanski's  tumor,  on  the  other  hand,  are  nearly  always  bilateral. 
Even  in  unilateral  cases  of  ovarian  cysts  the  other  ovary  very  fre- 
quently shows  beginning  cystic  degeneration. 

Pedicle. — Ovarian  cysts  in  most  cases  rise  up  into  the  abdomen, 
and  are  connected  with  the  uterus  by  means  of  a  pedicle,  which  facil- 
itates their  removal.  In  some  cases,  however, — and  we  have  seen  that 
this  applies  particularly  to  the  papillary  variety, — the  development 
takes  place  downward,  so  that  the  cyst  is  situated  between  the  layers 
of  the  broad  ligament,  more  or  less  close  up  to  the  uterus,  and  has  no 
pedicle. 

The  pedicle  of  ovarian  cysts  varies  much  in  size  and  composition. 
It  may  be  long  or  short,  thick  or  thin,  broad  or  narrow.  It  contains 
always  the  ligament  of  the  ovary  and  part  of  the  broad  ligament,  and, 
as  the  tumor  grows,  the  Fallopian  tube  is  drawn  in,  so  as  to  form  part 
of  it.  The  tube,  as  a  rule,  is  both  elongated  and  thickened.  The 
arteries  may  become  as  thick  as  the  radial,  and  the  veins  as  a  finger. 
Besides  there  are  lymphatics,  nerves,  smooth  muscle-fibres,  and  con- 
nective tissue,  all  forming  a  bundle  covered  by  a  peritoneal  sheath. 

Torsion  of  Pedicle. — The  longer  and  thinner  the  pedicle  is,  the 
more  easily  it  may  become  twisted,  the  tumor  rotating  around  its 
perpendicular  axis.  Such  rotation  can  only  occur,  if  there  are  no 
adhesions,  and  the  tumor  is  of  moderate  size.  It  is  probably  due  to 
the  peristaltic  movement  of  the  intestine,  the  differences  in  the  state 
of  emptiness  and  fulness  of  intestine  and  bladder,  the  irregular 
development  of  secondary  cysts,  by  which  the  centre  of  gravity 
changes,  and  to  the  movements  of  the  patients.  It  is  often  caused  by 
the  development  of  the  pregnant  uterus.  It  is  much  more '  frequent 
with  dermoid  than  other  ovarian  cysts. 

Sudden  twisting  of  the  pedicle  leads  to  gangrene  and  fatal  peri- 
tonitis. If  it  develops  slowly,  it  causes  edema  and  hyperemia  of  the 


DISEASES  OF  THE  OVARIES.  585 

wall,  hemorrhage  into  the  wall  and  the  cystic  cavity,  or  suppuration. 
The  cyst-wall  is  dark  red,  nearly  black.  If  the  torsion  continues, 
the  whole  pedicle  may  be  severed,  but  in  the  mean  time,  as  a  rule, 
adhesions  form  with  other  organs,  from  which  the  tumor  henceforth 
draws  its  nourishment.  Even  the  uterus  has  been  found  as  part  of 
the  severed  mass. 

The  rotation  of  the  tumor  and  twisting  of  the  pedicle  may  involve 
the  intestine,  and  cause  its  occlusion.  On  the  other  hand,  the  twist- 
ing may  effect  a  cure  of  the  cyst  by  causing  atrophy,  fatty  degenera- 
tion, and  calcification  of  the  diminished  tumor. 

Adhesions. — As  long  as  the  ovarian  cyst  is  covered  by  its  columnar 
epithelium,  it  slides  freely  over  the  surfaces  with  which  it  comes  in  con- 
tact ;  but,  when  the  epithelium  is  rubbed  off  or  covered  by  inflamma- 
tory exudation,  adhesions  to  the  surroundings,  such  as  the  bladder,  the 
uterus,  the  intestine,  the  omentum,  the  liver,  the  abdominal  wall,  etc., 
are  easily  formed.  These  adhesions  may  be  like  long  strings,  which 
are  easily  torn  or  divided  between  two  ligatures;  or  extend  over  a 
large  surface,  when  they  may  place  considerable  difficulties  in  the 
way  of  the  removal  of  the  tumors.  By  extending  downward  between 
the  layers  of  the  broad  ligament  and  into  its  base,  the  tumor  may  be- 
come adherent  to  the  ureter  and  the  large  blood-vessels  of  the  pelvis. 

Aseites. — An  accumulation  of  ascitic  fluid  in  the  peritoneal  cavity 
sometimes  accompanies  an  ovarian  cyst,  especially  the  proliferating 
papillary  variety.  The  fluid  may  be  mixed  with  blood,  which  is  a 
sign  of  a  deteriorated  constitution. 

Fusion. — When  an  ovarian  tumor  develops  in  each  ovary,  the  two 
may  become  adherent  to  each  other  in  the  abdomen  ;  the  common  par- 
tition may  be  absorbed,  and  the  two  form  one  tumor  with  this  peculi- 
arity that  it  has  two  pedicles,  one  attached  to  each  cornu  of  the  uterus. 

Intraligamentous  and  Extraperitoneal  Development. — We  have  seen 
that  while  most  ovarian  cysts  have  a  pedicle,  some  are  sessile.  They 
develop  downward  between  the  layers  of  the  broad  ligament,  and 
may  extend  far  away  from  their  base  outside  of  the  peritoneum, 
going  in  between  the  uterus  and  the  rectum  or  the  uterus  and  the 
bladder,  and  reaching  the  caecum,  colon  ascendens,  and  even  the 
kidney. 

All  kinds  of  ovarian  cysts  are  liable  to  become  retroperitoneal  in 
this  way,  but  this  development  is  found  most  frequently  in  papillary 
proliferating  cysts. 

Hemorrhage. — At  times  more  or  less  considerable  amounts  of 
blood  may  be  poured  into  the  cystic  fluid,  with  which  it  mixes, 
and  to  which  it  imparts  a  dark  red  or  brown  color.  This  hemor- 
rhage may  come  from  erosion  of  vessels  in  the  partitions  which  are 
being  absorbed,  from  ulceration  of  the  wall,  or  torsion  of  the 
pedicle. 


586  DISEASES  OF  WOMEN. 

Suppuration. — The  wall  of  a  cyst  may  become  inflamed,  and  the 
contents  changed  to  pus.  This  grave  accident  may  be  due  to  torsion 
of  the  pedicle,  but  is  most  frequently  attributable  to  puncturing  of 
the  cyst  without  sufficient  antiseptic  precautions.  It  may  be  caused 
by  puerperal  infection  or  occur  spontaneously.  In  the  latter  case 
pyogenic  bacilli  are  supposed  to  have  worked  their  way  in  from  the 
outer  world  through  the  genital  canal  or  the  intestine. 

Rupture. — An  ovarian  cyst  may  burst  and  pour  part  of  its  con- 
tents into  the  peritoneal  cavity,  where  a  bland  fluid  is  absorbed  and 
eliminated,  especially  by  the  kidneys.  Even  thick  colloid  con- 
tents of  cysts,  if  not  mixed  with  blood  or  pus,  do  not  irritate  the 
peritoneum,  although  their  absorption  requires  more  time.  But  bloody, 
purulent,  or  ichorous  fluid,  as  well  as  the  contents  of  dermoid  cysts, 
causes  more  or  less  violent  peritonitis  or  death  from  shock. 

The  rupture  into  the  peritoneal  cavity  may  give  rise  to  the  for- 
mation of  a  metastatic  tumor  of  the  peritoneum,  of  which  more  will 
be  said  presently. 

Rupture  may  also  occur  into  the  intestine,  the  stomach,  the  vagina, 
the  bladder,  the  Fallopian  tube,  or  through  the  abdominal  wall, 
especially  the  umbilicus. 

Under  favorable  circumstances  the  rupture  may  effect  a  cure  of  the 
disease. 

Evidence  of  rupture  is  found  in  8  or  10  per  cent,  of  all  ovarioto- 
mies. This  accident  may  be  due  to  a  fall,  a  blow,  a  kick,  or  similar 
violence.  It  may  also  be  caused  by  torsion  of  the  pedicle,  by  great 
thinness  and  brittleness  of  the  wall,  by  the  development  of  unusu- 
ally numerous  secondary  cysts  or  perforating  papillomata,  fatty  de- 
generation, or  hemorrhage  into  the  cyst. 

Calcification  and  Ossification. — We  have  mentioned  above  (p.  575) 
that  frequently  calcareous  incrustations  form  hard  plates  in  the  cyst- 
wall.  This  process  may  acquire  such  proportions  that  the  whole 
tumor  is  changed  into  a  hard  shell,  in  which  even  bone-corpuscles 
may  be  found. 

Cancerous  Degeneration. — "We  have  seen  above  (p.  576)  that  the 
proliferating  glandular  myxoid  cystoma  may  become  malignant.  The 
same  is  the  case  with  dermoid  cysts,  and  when  once  degeneration  into 
sarcoma  or  carcinoma  has  taken  place,  not  only  neighboring  organs 
may  be  involved,  but  metastatic  deposits  may  form  in  remote  parts 
of  the  body.  It  has  been  found  that  20  per  cent,  or  more  of  all 
ovarian  tumors  become  cancerous. 

Metastasis. — Papillomatous  cysts  have  a  tendency  to  cause  the  pro- 
duction of  small  yellow  nodules  on  the  peritoneum.  After  removal  of 
the  tumor  these  may  disappear  or  become  innocuous  by  becoming 
calcified. 

Glandular  and  dermoid  cysts  are  much  less  liable  to  form  such 


DISEASES  OF  THE  OVARIES.  587 

metastases,  except  the  glandular  variety  with  gelatinous — i.  e.  serai- 
solid — contents.  When  in  consequence  of  rupture  of  the  cyst  before 
or  during  operation  part  of  the  contents  enters  the  peritoneal  cavity, 
it  has  in  some  rare  cases  given  rise  to  the  formation  of  large  gelat- 
inous masses  covering  the  peritoneum ;  which  condition  is  called 
pseudomyxoma  of  the  peritoneum  (Werth)  or  gelatinous  disease  of 
the  peritoneum  (Pean).1 

The  gelatin  is  held  in  the  meshes  of  fine  membranes  of  connec- 
tive tissue,  which  may  be  covered  with  endothelium  or  columnar  epi- 
thelium, and  carry  fine  blood-vessels.  In,  some  cases  this  formation 
may  be  explained  as  a  transformed  peritonitis,  but  in  others  it  is  cer- 
tainly a  growth  of  small  solid  particles  of  the  tumor  which  go  on 
forming  a  tumor  in  the  peritoneum  similar  to  the  one  in  the  ovary, 
from  which  they  Avere  broken  loose  at  the  time  of  the  operation. 

The  Origin  of  Ovarian  Cysts. — In  speaking  of  the  division  of 
ovarian  cysts  into  different  classes  (p.  567)  we  have  seen  that  one 
class,  the  so-called  dropsy  of  the  Graafian  follicles,  is  indisputably 
formed  by  a  pathological  development  of  one  or  more  of  such  folli- 
cles. It  is  likewise  sure  that  a  corpus  luteum  may  be  converted 
into  a  cyst.  As  a  rule,  the  cysts  of  this  origin  remain  small  as  a 
hazelnut ;  but  they  may  attain  the  size  of  an  adult's  head. 

As  to  the  second  class,  the  proliferating  cysts,  there  reigns  yet  con- 
siderable diversity  of  opinion  in  regard  to  their  origin,  and  it  is  very 
likely  that  it  differs  in  different  cases.  Microscopical  examination 
has  shown  that  both  the  glandular  and  the  papillary  variety  may  de- 
velop from  a  Graafian  follicle.  Another  source  may  be  the  germinal 
epithelium,  which  in  some  ovaries,  even  of  adults,  forms  pouches 
extending  into  the  stroma  of  the  ovary,  much  like  the  columns  of 
epithelial  cells  giving  rise  to  the  primordial  ova  and  primary  folli- 
cles (p.  28).  Even  those  tumors  which  have  ciliated  epithelium 
may  have  this  origin,  as  part  of  the  ovary,  probably  by  extension 
from  the  tube,  may  have  ciliated  external  epithelium  instead  of  plain 
columnar.  Some  claim  that  the  papillary  cystomas  are  developed 
from  remnants  of  the  Wolffian  body  growing  into  the  ovary  from 
the  hilum,2 

The  source  of  the  glandular  variety  is  by  some  thought  to  be  a  de- 
generation of  the  intima  of  the  arteries  in  the  ovary.  Colloid  deposits 
are  often  found  in  the  stroma,  the  Graafian  follicles,  or  a  corpus 
luteum ;  but  there  is  no  evidence  that  they  are  the  starting-point  of 
proliferating  cysts.  We  find,  likewise,  frequently  small  cysts  without 
epithelium  in  the  ovaries,  but  it  is  unlikely  that  formations  of  so  epi- 

1  A  case  of  the  kind  is  described  on  p.  46  of  my  Diagnosis. 

2  In  regard  to  the  histogenesis  of  the  papillary  cystomata  of  the  ovary  a  good 
synopsis  of  known  facts  and  valuable  new  observations  are  found  in  articles  by  J. 
Whitridge  Williams  in  Johns  Hopkins  Hospital  Bulletin,  No.  18,  December,  1891,  and 
Report  in  Pathology,  II.,  Baltimore,  1892. 


588  DISEASES  OF  WOMEN. 

thelial  a  character  as  proliferating  cystomas  originate  in  them.  It  is 
not  proved  that  connective  tissue  can  be  transformed  into  epithelium, 
and  it  is,  therefore,  unlikely  that  proliferating  cystomas  can  develop 
from  the  stroma  of  the  ovary. 

As  to  the  origin  of  dermoid  cysts,  the  generally  accepted  theory  is 
that  of  invagination.  The  ovary  is  developed  from  the  axis-cord,  in 
which  it  is  impossible  to  distinguish  the  individual  blastodermic  layers. 
In  the  collection  of  mesoblastic  cells  destined  to  form  the  ovary  may  be 
included  cells  belonging  to  the  epiblast,  to  the  hypoblast  or  to  other 
parts  of  the  mesoblast  than  those  required  for  the  ovary.  This  hap- 
pens most  commonly  with  the  epiblastic  cells,  which  form  epidermis, 
teeth,  nails,  hair,  the  cutaneous  glands,  and  the  central  nervous  sys- 
tem ;  more  rarely  with  the  mesoblastic  cells,  forming  bone,  cartilage, 
and  muscle-tissue;  and  least  frequently  with  the  hypoblastic  cells, 
whose  role  it  is  to  form  the  epithelium  of  the  intestine  and  the  glands 
connected  with  it. 

When  not  only  extraneous  tissue,  but  more  or  less  perfectly  formed 
organs  are  found  in  a  dermoid  cyst,  it  is,  however,  a  question  if  this 
must  not  rather  be  looked  upon  as  a  case  of  foetus  in  fcetu ;  that  is, 
two  fetuses,  one  of  which  has  hardly  developed  and  is  included  in 
the  other. 

Etiology. — Little  or  nothing  is  known  about  the  circumstances  that 
cause  the  development  of  ovarian  cysts.  They  are  met  with  at  all 
ages.  Simple  cysts  have  been  found  in  the  ovaries  of  fetuses.  In 
young  children  even  multilocular  cystomas  have  been  found  in  a  small 
number  of  cases,  and  Fig.  298  (p.  575)  represents  a  congenital  cystoma 
of  this  kind.  Before  puberty  the  dermoid  variety  predominates. 

Commonly  ovarian  cysts  appear,  however,  during  the  period  of 
greatest  sexual  activity,  between  the  ages  of  twenty  and  fifty  years. 

Single  women  are  proportionately  much  more  liable  to  the  disease 
than  married,  the  reason  for  which  may  be  sought  in  the  physiolog- 
ical rest  which  the  ovaries  enjoy  during  pregnancy  and  lactation. 

Sometimes  several  members  of  one  family  are  affected,  which  points 
to  a  hereditary  disposition. 

Some  think  chronic  oophoritis  is  the  cause ;  others  have  taken 
chlorosis  to  be  a  factor  in  the  production  of  ovarian  cysts :  the 
monthly  congestion  in  these  patients  is  insufficient  to  cause  a  men- 
strual discharge,  but  strong  enough  to  produce  hypertrophy  of  the 
walls  of  the  follicle,  and  thus  start  the  development  of  a  cyst. 

Symptoms. — If  the  tumor  can  rise  freely  into  the  abdominal  cav- 
ity, it  may  pass  unnoticed  until  it  is  large  enough  to  give  the  patient 
the  appearance  of  being  in  a  state  of  advanced  pregnancy. '  But,  as 
a  rule,  it  gives  rise  before  that  to  diverse  abnormalities. 

Quite  commonly  she  complains  of  pain  in  one  or  both  sides  of  the 
pelvis  or  the  sacral  region.  In  some  patients  each  menstruation  is 


DISEASES  OF  THE  OVARIES.  589 

accompanied  by  pain,  fever,  and  increase  in  size  of  the  tumor,  which 
symptoms  are  doubtless  due  to  congestion.  Sometimes  the  pain  occurs 
regularly  about  a  week  after  menstruation  as  a  kind  of  intermenstrual 
pain  (p.  417). 

As  a  rule,  the  patient  has  an  abnormal  sensation  in  walking,  sitting 
down,  or  rising.  Often  she  complains  of  cold  feet,  probably  due  to 
an  imperfect  circulation. 

In  the  beginning  there  are  no  menstrual  disturbances ;  but,  when 
the  tumor  becomes  large,  it  is  often  accompanied  by  menorrhagia, 
especially  if  it  is  intraligameutous ;  and  still  later,  when  all  ovarian 
tissue  has  disappeared,  menstruation  often  ceases  altogether.  On  the 
other  hand,  even  after  the  menopause  new  hemorrhagic  discharges 
from  the  uterus  may  occur. 

Even  if  menstruation  takes  place,  and  only  one  ovary  is  affected, 
the  patients  are  often  sterile,  which  may  be  due  to  the  diminished 
number  of  ovules,  a  more  difficult  ovulation,  inflammatory  deposits, 
tubal  disease,  the  displacement  of  the  uterus,  or  endometritis.  On 
the  other  hand,  women  with  two  large  ovarian  cysts  may  yet  occa- 
sionally become  impregnated,  but  their  pregnancy  is  often  cut  short 
by  abortion. 

Like  other  abdominal  tumors,  and,  on  account  of  the  enormous  size 
they  sometimes  attain,  in  a  higher  degree  than  most  others,  ovarian 
tumors  give  rise  to  a  series  of  symptoms,  all  of  which  are  referable 
to  pressure. 

If  the  tumor  is  prevented  by  intraligamentous  development,  adhe- 
sions, or  shortness  of  the  pedicle  from  rising  up  into  the  abdominal 
cavity,  symptoms  of  this  class  begin  as  soon  as  the  tumor  reaches  the 
size  of  a  fetal  head.  If,  on  the  other  hand,  it  leaves  the  pelvis,  they 
come  much  later.  Pressure  on  the  bladder  causes  frequent  micturi- 
tion ;  that  on  the  rectum,  constipation.  Moderate  compression  of  the 
ureters  leads  to  a  scanty  excretion  of  urine.  If  one  of  them  becomes 
closed,  the  urine  accumulates  above  the  stricture  and  in  the  pelvis  of 
the  corresponding  kidney,  causing  hydrouephrosis  and  uremia.  Press- 
ure on  the  hemorrhoidal  veins  or  on  the  trunks  to  which  they  carry  the 
blood — the  internal  iliac  and  the  superior  mesenteric — is  conducive  to 
the  formation  of  hemorrhoids.  The  pressure  on  the  internal  iliac 
veins  and  the  vena  cava  inferior  may  become  so  great  that  these  chan- 
nels practically  become  impervious.  Under  such  circumstances  the 
blood  finds  an  outlet  through  the  deep  and  the  superficial  epigastric 
veins,  the  roots  of  which  anastomose  with  those  of  the  internal  mam- 
mary vein ;  but,  as  a  result  of  the  increase  of  the  blood  carried,  the 
veins  on  the  lower  part  of  the  abdomen  become  much  enlarged. 

The  uterus  is  pushed  over  to  the  opposite  side  by  a  lateral  cyst. 
If  both  ovaries  are  cystic,  they  push  the  uterus  forward.  In  the  begin- 
ning the  uterus  lies,  as  a  rule,  in  front  of  the  ovarian  cyst,  but  later 


590  DISEASES  OF  WOMEN. 

behind  it.  The  pressure  may  become  so  great  that  it  becomes  pro- 
lapsed. 

Pressure  on  the  stomach  is  accompanied  by  nausea,  vomiting,  and 
anorexia.  The  liver  may  become  flattened,  and  in  rare  cases  jaundice 
appears  as  a  sign  of  compression  of  this  organ  or  the  excretory  ducts 
destined  to  convey  the  bile  to  the  intestine.  The  apex  of  the  heart 
may  be  pressed  outward  and  upward,  so  that  the  whole  organ  occu- 
pies a  more  horizontal  position. 

Even  the  substance  of  the  heart  is  apt  to  undergo  fatty  degener- 
ation or  brown  induration,  which  may  become  a  cause  of  sudden 
death.  The  compression  of  the  lungs  gives  rise  to  rapid  and  super- 
ficial respiration.  In  rare  cases  a  serous  exudation  takes  place  into  the 
cavity  of  the  pleura.  Even  the  lower  ribs  and  the  ensiform  process 
may  be  turned  outward. 

Interference  with  the  free  circulation  in  the  femoral  and  ex- 
ternal iliac  veins  causes  varicosities  and  edema  of  the  legs  and  labia 
majora,  which  are  still  more  increased,  when  the  stagnation  results  in 
the  formation  of  a  thrombus  in  those  large  venous  trunks.  Rarely 
neuralgia  appears  in  the  legs  in  consequence  of  pressure  on  the  sacral 
plexus  or  the  large  trunks  innervating  the  lower  extremities.  Some- 
times a  certain  variability  is  observed  in  the  pressure-symptoms. 
They  increase  during  congestion  of  the  tumor  and  diminish  in  conse- 
quence of  profuse  menstruation,  diarrhea,  and  abundant  diuresis. 

In  some  cases  a  blowing  sound  may  be  heard  with  the  stethoscope 
on  the  abdomen,  like  the  uterine  souffle  of  pregnancy.  It  is  probably 
due  to  compression  of  the  large  blood-vessels  of  the  pelvis.  The 
abdominal  wall  becomes  thin,  the  umbilicus  protrudes,  and  the  skin  is 
the  seat  of  striae,  due  to  rupture  of  the  corium.  This  tension  of  the 
skin  may  be  accompanied  by  painful  burning  and  exasperating  itch- 
ing, which  disturb  the  sleep  of  the  patient. 

A  symptom  that  often  is  the  first  to  bring  the  patient  to  the  phy- 
sician is  the  increase  in  size  of  the  abdomen.  Sometimes  she  can 
distinctly  tell  that  the  swelling  has  begun  in  one  iliac  fossa ;  and,  per- 
haps, we  can  yet  feel  it  there  ourselves ;  but  when  the  tumor  grows 
large,  it  becomes  central  and  fills  the  abdomen.  The  rapidity  with 
which  it  grows  varies  much.  The  glandular  variety  grows  fastest  of 
all,  and  becomes  largest ;  the  papillary  grows  more  slowTly,  and  does 
not  acquire  such  large  proportions;  the  paucilocular  dropsy  of  the 
Graafian  follicles  and  a  monocystic  dermoid  cyst  develop  most  slowly 
and  remain  smallest  of  all. 

The  larger  the  tumor  becomes,  the  more  the  patient  leans  backward 
in  order  to  move  the  center  of  gravity  into  a  more  favorable  .position, 
just  as  a  pregnant  woman  does.  When  the  growth  becomes  too  heavy 
and  unwieldy,  she  cannot  walk  at  all.  She  cannot  even  lie  on  her  back, 
but  only  on  the  side,  and  can  only  turn  with  the  assistance  of  others. 


DISEASES  OF  THE  OVARIES. 


591 


In  the  beginning  the  general  health  is  good,  but  soon  the  patient 
begins  to  lose  flesh  and  strength.  Digestion,  respiration,  circulation, 
innervation,  all  suffer.  Sleep  is  often  disturbed.  Pain,  anxiety,  and 
loss  of  adipose  tissue  give  her  face  a  peculiar  expression,  the  so-called 
fades  ovariana  (Fig.  317),  characterized  by  pinched  features  and  deep- 
ening furrows. 

FIG.  317. 


Fades  Ovariana  (Spencer  Wells). 


In  rare  cases  the  breasts  may  undergo  a  development  similar  to 
that  of  pregnancy.  Sometimes  aphthous  stomatitis  develops  toward 
the  end. 

As  a  rule,  the  disease  ends  fatally,  and  many  are  the  ways  in  which 
death  is  incurred.  It  may  be  due  to  lack  of  nutrition,  dyspnoea, 
hydrothorax,  pleurisy,  pneumonia,  insomnia,  exhaustion,  heart-dis- 
ease, hydronephrosis,  nephritis,  uremia,  hemorrhage  into  the  cyst, 
inflammation  and  suppuration  of  the  cyst,  rupture  into  the  peritoneal 
cavity,  twisting  of  the  pedicle,  acute  or  chronic  peritonitis,  cancerous 
degeneration,  etc. 

By  physical  examination  the  presence  of  a  tumor  is  made  out.  If 
the  patient  is  nervous  and  contracts  her  abdominal  muscles,  it  may  be 
necessary  to  anesthetize  her  (p.  161),  and  certain  details  in  regard  to 
the  pedicle  can  only  be  ascertained  in  this  condition. 


592  DISEASES  OF  WOMEN. 

A  complete  examination  is  to  be  made  both  of  the  pelvis  and  the 
abdomen  (pp.  139,  157,  et  seq.). 

By  bimanual  examination  (p.  141)  we  may  find  the  womb  dis- 
placed, as  described  above  in  speaking  of  pressure,  or  we  may  find 
the  vagina  elongated  by  being  pulled  up  by  the  tumor  and  ending  as 
a  funnel-shaped  canal,  the  vaginal  portion  of  the  uterus  having  dis- 
appeared. If  the  tumor  is  confined  to  the  pelvis,  we  will  feel  it  as 
a  globular  elastic  mass  to  one  side  of  or  behind  the  uterus.  As  a 
rule,  the  tension  of  the  cyst  is  too  great  to  allow  fluctuation  to  be 
felt. 

Even  when  the  tumor  is  developed  in  the  broad  ligament,  close  up 
to  the  edge  of  the  uterus,  a  shallow  furrow  between  the  two  indicates 
the  line  of  demarkation.  In  cases  of  large  tumors  part  of  the  cyst 
may  be  felt  in  the  pelvis. 

The  independence  of  the  uterus  is  also  made  out  by  introducing  a 
sound  and  moving  the  uterus.  The  cavity  of  the  uterus  is  often 
somewhat  deeper  than  normal.  Often  a  larger  part  of  the  tumor 
may  be  felt  through  the  rectum  than  through  the  vagina.  Some- 
times external  papillomata  may  be  felt  through  the  rectum  or  the 
vaginal  roof. 

If  the  tumor  extends  into  the  abdomen,  we  notice  by  inspection 
that  the  abdomen  is  more  prominent  than  usual.  By  palpation  we 
feel  the  resistance  offered  by  the  tumor,  judge  of  the  mobility  or  im- 
mobility of  the  same,  and  in  most  cases  feel  fluctuation.  We  fold  the 
abdominal  wall  in  front  of  the  tumor,  and  move  it  in  different  direc- 
tions, and  move  the  tumor  from  side  to  side  and  up  and  down.  In 
order  to  feel  the  pedicle,  one  assistant  pulls  the  uterus  down  with  a 
volsella,  another  lifts  the  tumor,  and  the  surgeon  tries  to  feel  the  hard 
string  extending  from  one  to  the  other. 

In  palpating  an  ovarian  tumor  we  sometimes  hear  and  feel  a  super- 
ficial crepitation,  which  is  explained  in  different  ways.  I  believe  it  to 
originate  in  fresh  adhesions  between  the  tumor  and  the  abdominal 
wall,  as  I  have  noticed  almost  identically  the  same  sensation  in  peel- 
ing off  the  membranes  from  the  inside  of  the  uterus  in  performing 
Cesarean  section. 

Percussion  elicits  a  dull  sound  over  the  tumor,  surrounded  on 
both  sides  and  above  by  an  area  of  tympanitic  resonance  due  to  the 
intestine. 

Auscultation  permits  us  sometimes  to  hear  a  blowing  sound  in 
enlarged  and  partially  compressed  blood-vessels. 

The  following  measures  should  be  taken  with  a  tape  measure : 
the  circumference  at  the  level  of  the  umbilicus  and  at  the  most  prom- 
inent point,  if  that  measure  differs  from  the  first ;  the  distance  from 
the  symphysis  to  the  umbilicus  and  from  the  umbilicus  to  the  ensi- 
form  process,  and  to  both  anterior  superior  spines  of  the  ilium.  In 


DISEASES  OF  THE  OVARIES.  593 

tumors  of  moderate  size  the  distance  from  the  symphysis  to  the 
umbilicus  is  longer  than  from  the  latter  to  the  ensiform  process,  and 
the  distance  from  the  umbilicus  to  the  anterior  superior  spine  of  the 
ilium  is  greater  on  that  side  where  the  tumor  is  situated.  In  very 
large  tumors  these  differences  disappear. 

In  the  course  of  the  development  of  ovarian  cysts  some  accidents 
may  occur,  the  clinical  aspects  of  which  would  require  special 
attention — namely,  hemorrhage,  inflammation,  suppuration,  twist- 
ing of  the  pedicle,  rupture,  ascites,  peritonitis,  and  intestinal 
obstruction. 

Hemorrhage. — Small  amounts  of  blood  are  frequently  mixed  with 
the  cystic  fluid  without  giving  rise  to  any  symptoms,  but  if  the  intra- 
cystic  bleeding  is  considerable,  it  may  even  jeopardize  the  patient's 
life.  This  occurrence  is  marked  by  a  sudden  increase  in  the  size  of  the 
tumor,  a  weak  pulse,  dyspnoea,  fainting,  pallor,  and  a  cold,  clammy 
skin.  While  a  moderate  bleeding  may,  perhaps,  be  arrested  by  means 
of  an  ice-bag  placed  on  the  abdomen,  signs  of  serious  internal  hemor- 
rhage call  for  immediate  ovariotomy. 

Inflammation  and  Suppuration. — The  cyst  may  become  inflamed, 
which  is  accompanied  by  fever,  pain,  and  tenderness  of  the  tumor. 
If  the  inflammation  passes  into  suppuration,  the  patient  is  seized  with 
more  or  less  regularly  recurring  rigors,  followed  by  profuse  perspira- 
tion and  high  temperature.  Simple  inflammation  is  treated  success- 
fully with  ice-bags,  while  suppuration  is  an  indication  for  immediate 
removal  of  the  cyst. 

Torsion  of  the  Pedicle. — If  torsion  takes  place  very  slowly,  it  may 
develop  without  appreciable  symptoms,  except  a  gradual  diminution 
of  the  tumor,  but  if  it  occurs  suddenly,  it  is  accompanied  by  rapid 
enlargement  of  the  cyst,  pain,  tenderness,  incessant  vomiting,  the 
vomit  soon  becoming  green  in  color,  and  acceleration  of  the  pulse. 
The  torsion  may  be  temporary.  With  its  cessation  the  symptoms 
stop.  If  it  continues,  it  may  lead  to  ascites,  internal  hemorrhage, 
rupture  of  the  cyst,  suppuration,  peritonitis,  or  gangrene  of  the 
tumor.  But  it  may  also  follow  a  more  chronic  course,  and  end  the 
patient's  life  by  slow  infection  and  marasmus.  If  the  diagnosis  of 
torsion  of  the  pedicle  can  be  made,  ovariotomy  should  be  performed 
at  once. 

Rupture  of  the  Oyst. — Rupture  into  the  peritoneal  cavity  of  small 
cysts  with  serous  contents  need  not  produce  any  symptoms.  If  the 
cyst  is  large  and  the  contents  watery,  the  fluid  is  soon  absorbed  and 
disposed  of  by  increased  diuresis  and  perspiration.  Colloid  fluid  may 
remain  for  months  in  the  peritoneal  cavity. 

The  rupture  of  a  cyst  with  bloody  contents  may  be  followed  by 
the  development  of  a  retro-uterine  hematocele. 

If  pus  or  other  irritant  fluid  is  poured  into  the  peritoneal  cavity, 


594  DISEASES  OF  WOMEN. 

it  sets  up  general  peritonitis.  Smaller  amounts  of  fluid  may,  how- 
ever, only  cause  local  peritonitis  and  adhesions. 

If  a  large  cyst  ruptures  into  the  peritoneal  cavity,  the  patient  has 
a  sensation  of  something  giving  way,  is  seized  with  sudden  severe 
pain  and  faiutness.  The  surgeon  can  feel  the  fluid  move  freely  in  the 
peritoneal  cavity.  In  rare  cases  a  new  large  tumor  may  form  in  the 
peritoneal  cavity  (p.  587). 

In  some  cases  rupture  occurs  repeatedly,  each  time  accompanied 
by  temporary  diminution  of  the  cyst  and  symptoms  of  peritonitis. 

The  effects  of  rupture  being  so  very  different,  the  appropriate 
treatment  must  be  decided  on  in  each  case  according  to  circumstances. 

If  the  symptoms  are  at  all  alarming,  ovariotomy  should  be  per- 
formed at  once. 

The  rupture  into  the  stomach  is  marked  by  vomiting  of  cystic  fluid. 
That  into  the  intestine  is  evidenced  by  evacuation  of  the  fluid  through 
the  anus,  and  diarrhoea.  When  rupture  takes  place  into  the  bladder, 
cystic  fluid,  hairs,  and  teeth  may  be  evacuated  with  the  urine.  If 
the  cyst  ruptures  into  the  vagina,  the  contents  are  evacuated  through 
the  vulva. 

The  evacuation  through  a  hollow  organ  or  through  the  skin,  like 
that  into  the  peritoneal  cavity,  may  be  intermittent.  If  the  com- 
munication has  taken  place  with  the  intestine,  no  infection  need  take 
place,  the  opening  being  small  and  valvular,  or  being  kept  temporarily 
closed  by  the  inside  of  the  cyst-wall  applying  itself  against  it. 

The  rupture  through  a  hollow  organ  may  effect  a  spontaneous  cure. 
It  is,  therefore,  wise  to  await  developments  before  undertaking  any 
dangerous  operation. 

Ascites. — -Serous  fluid  may  accumulate  in  the  peritoneal  cavity, 
outside  of  the  tumor,  in  consequence  of  chronic  peritonitis,  torsion 
of  the  pedicle,  rupture  of  the  cyst,  hydronephrosis,  and,  perhaps, 
pressure  on  the  vena  porta.  Papillary  cystomas  are  particularly  apt 
to  be  surrounded  by  ascitic  fluid. 

A  moderate  amount  of  such  fluid  may  be  looked  upon  as  bene- 
ficial, as  it  prevents  the  formation  of  adhesions,  and,  therefore,  facili- 
tates the  removal  of  the  tumor.  A  large  collection  increases,  of 
course,  the  gravity  of  all  the  pressure-symptoms. 

Peritonitis. — Local  or  general  peritonitis,  characterized  by  the 
usual  symptoms, — fever,  vomiting,  pain  in  the  abdomen,  great  tender- 
ness, exudation,  and  tympanites, — is  a  very  common  accompaniment 
of  ovarian  cysts.  It  may  be  caused  by  friction,  torsion  of  the  pedi- 
cle, or  rupture  of  the  cyst.  It  leads  to  the  formation  of  adhesions 
which  render  the  removal  of  the  cyst  more  difficult  or  impossible. 
As  a  rule,  its  occurrence  should,  therefore,  be  met  by  immediate 
ovariotomy. 

Intestinal  Obstruction. — As  the  result  of  pressure  of  a  large  tumor 


DISEASES  OF  THE  OVARIES.  595 

on  the  intestine,  or  the  formation  of  adhesive  bands,  or  the  torsion 
of  the  pedicle,  involving  the  intestine  in  its  convolutions,  the  latter 
may  become  impervious — an  accident  characterized  by  the  usual 
symptoms,  constipation,  gaseous  distention,  pain,  and  vomiting, 
which  finally  becomes  stercoraceous.  This  grave  condition  calls  for 
immediate  ovariotomy. 

Explorative  Puncture. — The  practice  of  withdrawing  some  fluid 
from  the  tumor  by  thrusting  the  needle  of  an  aspirator  through  the  ab- 
dominal wall,  which  in  most  cases  gave  valuable  information  about 
the  nature  of  the  tumor,  has  practically  been  abandoned.  The  reasons 
of  this  change  are  that  a  blood-vessel  might  be  wounded ;  or  cystic 
fluid  find  its  way  into  the  peritoneal  cavity,  and  cause  peritonitis  or 
metastases,  especially  in  case  of  a  papillary  cystoma ;  or  suppuration 
be  brought  on  in  the  cyst,  which,  however,  can  be  avoided  by  using 
an  aseptic  syringe  and  disinfecting  the  skin ;  or  adhesion  be  caused 
between  the  cyst  and  the  wall.  I  believe,  however,  that  the  chief 
explanation  is  to  be  found  in  the  development  of  abdominal  surgery  : 
while  fifteen  or  twenty  years  ago  most  surgeons  avoided  operating 
on  other  tumors  than  ovarian  cysts,  they  are  now  prepared  to  attack 
whatever  they  may  find  after  opening  the  abdomen. 

Aspiration  through  the  vagina  is  yet  frequently  used  in  different 
pelvic  disorders,  and  thus  familiarity  with  the  fluid  of  ovarian  cysts 
is  still  of  importance,  both  for  diagnostic  and  curative  purposes. 

Diagnostic  Value  of  the  Examination  of  the  Fluid. — By  studying 
the  physical,  chemical,  and  microscopical  characters  of  the  fluid,  it  is 
almost  always  possible  to  diagnosticate  ovarian  cysts  from  others. 
Myxoid  ovarian  fluid  has  in  most  cases  a  certain  appearance  by 
which  it  can  be  recognized  at  once  simply  by  looking  at  it. 

Viscidity  is  the  most  important  physical  character  when  present, 
but  it  may  exceptionally  be  wanting  in  ovarian  and  present  in  non- 
ovarian  fluid. 

No  chemical  product  peculiar  to  ovarian  cysts  has  been  found. 

As  a  rule,  the  fluid  of  an  ovarian  cyst  does  not  coagulate  sponta- 
neously, and,  when  it  does,  the  coagulation  takes  place  slowly.  As- 
citic  fluid,  as  a  rule,  coagulates  spontaneously  and  slowly,  forming  a 
small  coagulum.  The  fluid  of  uterine  fibrocysts  sometimes  coagu- 
lates, and  then  immediately  after  being  evacuated  and  en  masse. 

Ovarian  fluid,  as  a  rule,  coagulates  to  a  great  extent  or  entirely  by 
heat.  That  of  the  cysts  of  the  broad  ligament  does  not  coagulate 
by  heat,  unless  an  acid  is  added. 

There  is  no  pathognomonic  morphological  element  in  ovarian  fluid. 
The  most  important  element  in  regard  to  diagnosis  is  columnar  epi- 
thelial cells  seen  in  side  view.  Their  presence  excludes  all  other 
tumors  than  those  of  the  ovary,  the  Fallopian  tube,  and  the  broad 
ligament  (perhaps  with  the  exception  of  the  rare  pancreas-cysts). 


596  DISEASES  OF  WOMEN. 

Although  the  small  granular  bodies  described  above,  and  represented 
in  Fig.  308,  may  be  found  in  very  different  fluids,  the  presence 
of  very  many  of  them  in  an  abdominal  cyst  is  a  strong  presumption 
in  favor  of  its  ovarian  origin. 

If  a  cystic  fluid  contains  hair  or  epidermis-cells  or  is  composed  of 
fluid  fat,  it  comes  from  a  dermoid  cyst ;  but  we  can  only  conclude 
that  it  is  ovarian,  if  besides  it  contains  the  just-mentioned  form- 
elements. 

A  fluid  as  clear  as  spring-water  and  containing  very  few  histolog- 
ical  elements  may  be  found  in  ovarian  cysts,  both  in  true  monocysts 
(hydrops  folliculi)  and  in  multilocular  cysts  with  ciliated  epithelium. 

Both  ovarian  cysts  and  cysts  of  the  broad  ligament  may  have 
serous  or  colloid  contents,  but  the  latter  is  common  in  ovarian  cysts, 
rare  in  extra-ovarian,  while  a  watery  fluid  is  common  in  extra-ovarian, 
rare  in  ovarian  cysts. 

Besides  the  information  gained  by  the  examination  of  the  abstracted 
fluid,  explorative  puncture  offers  the  advantage  that  many  relations 
of  a  cyst,  which  were  masked  as  long  as  it  was  full,  may  be  felt  after 
it  is  emptied.  As  to  the  modus  operandi,  see  p.  157. 

Explorative  Incision. — If  the  symptoms  and  signs  of  an  abdominal 
tumor  yet  leave  the  surgeon  in  doubt  as  to  its  being  ovarian  or  as  to 
the  possibility  of  its  removal,  resort  should  be  had  to  explorative 
laparotomy  (p.  159). 

Differential  Diagnosis. — The  diagnosis  of  abdominal  tumors  is 
often  so  difficult,  and  so  many  mistakes  have  been  made,  that  an 
operator  before  coming  to  a  final  conclusion,  and  especially  before 
beginning  an  operation,  should  bear  in  mind  the  mistakes  that  have 
been  recorded  and  the  means  of  avoiding  them. 

It  is  convenient  to  consider  separately  the  diagnosis  as  long  as  the 
tumor  is  confined  to  the  pelvis,  and  when  it  has  become  abdominal. 

A.  Pelvic  Tumor. 

An  ovarian  tumor  in  the  pelvis  should  be  differentiated  from  1, 
cellulitis ;  2,  peritonitis ;  3,  hydro-  and  pyosalpinx ;  4,  a  cyst  of  the 
broad  ligament ;  5,  hematoma  of  the  broad  ligament ;  6,  a  retroflexed 
gravid  uterus ;  7,  extra-uterine  pregnancy  ;  8,  retro-uterine  hemato- 
cele ;  9,  fibroid  and  fibrocystic  tumor  of  uterus ;  and  10,  solid  ovarian 
tumors. 

1.  Cellulitis  gives  the  history  of  inflammation,  and  as  a  probable 
cause,  labor  or  abortion.     The  swelling  is  hard  unless  an  abscess  has 
formed,  when  it  is  softer  than  a  cyst.     It  is  immovable.     The  limits 
are  less  distinct. 

2.  Peritonitis  gives  a  history  of  inflammation,  and  is  generally 
caused  by  the  use  of  the  sound,  some  operation  performed  on  the 


DISEASES  OF  THE  OVARIES.  597 

uterus,  or  gonorrheal  infection.  It  is  often  combined  with  endo- 
metritis  and  salpingitis.  The  swelling  is  immovable.  The  fluid  is 
serous,  never  viscid  or  ropy,  and  does  not  contain  columnar  epithelial 
cells. 

3.  Hydro-  and  Pyosalpinx  are  usually  bilateral,  and  form  long 
sausage-shaped  tumors. 

4.  Cysts  of  the  broad  ligament  have  very  distinct  fluctuation,  are 
less  tender,  and  contain,  as  a  rule,  a  fluid  that  is  thin,  colorless,  and 
does  not  coagulate  by  heat  before  the  addition  of  an  acid. 

5.  Hematoma  of  the  broad  ligament  appears  suddenly,  is  accom- 
panied by  pallor  and  fainting,  and  is  soon  reabsorbed. 

6.  The  retroflexed  gravid  uterus  is  accompanied  by  signs  of  preg- 
nancy, and  often  constipation  and  retention  of  urine.     The  mass  in 
Douglas's  pouch  is  continuous  with   the  cervix,  and   can  often    be 
replaced. 

7.  Extra-uterine  pregnancy  gives    the   signs   of   pregnancy.       A 
tumor   is  felt   either   independent  of  the  uterus  or  attached    to  it. 
The  patient  has  attacks  of  sudden,  violent  pelvic  pain.     Sometimes 
there  is  a  bloody  discharge    from   the    uterus  containing   decidual 
shreds. 

8.  Retro-uterine  hematocele  gives  a  history  of  sudden  abdominal 
pain  at  a  menstrual  period  or  of  menorrhagia,  followed  by  inflamma- 
tion.    The  tumor,  at  first  very  soft,  soon  becomes  hard. 

9.  Fibroids  of  the  uterus  are  hard,  situated  in  the  uterus  or  inti- 
mately connected  with  it.     The  uterus  has  an  irregular  shape.     Hard 
nodules  are  often  felt. 

Fibrocystic  tumors  may  be  fluctuating,  but  form  one  mass  with  the 
uterus,  and  hard  nodular  masses  are  likely  to  be  felt. 

10.  Solid  ovarian  tumors  are  much  rarer  than  cysts,  are  hard,  often 
nodular,  frequently  accompanied  by  ascites,  the  fluid  of  which  may,  if 
the   tumor   is   cancerous,  contain    large  round  or  pear-shaped  cells, 
isolated  or  in  groups,  and  with  single  large  nuclei. 

B.  Abdominal  Tumor. 

If  the  ovarian  tumor  has  risen  into  the  abdominal  cavity,  it  should 
be  differentiated  from  the  following  swellings:  1,  pregnancy  (normal, 
with  excess  of  liquor  amnii,  with  dead  child,  or  extra-uterine) ;  2,  hy- 
datiform  mole ;  3,  hematometra,  hydrometra  or  physometra ;  4,  fibroid 
or  fibrocystic  tumor  of  the  uterus;  5,  ascites ;  6,  hematocele ;  7,  encysted 
peritonitic  exudation  ;  8,  tuberculosis  of  the  peritoneum  ;  9,  cancer  of 
the  peritoneum  ;  10,  a  cyst  of  the  broad  ligament ;  11,  an  omental  cyst 
or  solid  tumor;  12,  hydronephrosis;  13,  a  renal  cyst ;  14,  a  floating 
kidney;  15,  a  hydatid;  16,  a  liver-cyst;  17,  a  floating  liver;  18, 
a  pancreas-cyst;  19,  a  cyst  or  solid  tumor  of  the  spleen;  20,  a  cyst 


598  DISEASES  OF  WOMEN. 

of  the  mesentery ;  21,  a  cyst  of  the  abdominal  wall ;  22,  a  solid  tumor 
or  swelling  of  the  abdominal  wall;  23,  hydrosalpinx ;  24,  spiua 
bifida  ;  25,  dilatation  of  the  stomach ;  26,  a  distended  bladder ;  27,. 
impacted  feces;  28,  tympanites;  and  29,  a  phantom  tumor. 

1.  Pregnancy  is  characterized  by  numerous  signs,  especially  the  fetal 
heart-sound,  fetal  movements  to  be  heard  and  felt,  parts  of  the  fetu& 
to  be  felt  by  vaginal  or  abdominal  examination,  ballottement,  purple 
color  of  the  vagina,  and  softening  of  the  cervix  and  lower  uterine 
segment.     The  tumor  forms  one  mass  with  the  cervix  and  is  con- 
tractile. 

In  hydramnion  the  fetal  heart-sounds  may  be  inaudible  and  the 
fetal  parts  may  be  difficult  to  feel,  but  we  have  the  history  and  other 
signs  of  pregnancy,  unusual  distention  of  the  lower  uterine  segment, 
and  sometimes  an  open  cervix,  allowing  the  examiner  to  place  the 
finger  right  on  the  ovum. 

Amniotic  fluid  differs  from  all  others  by  containing  large  flat  cells 
filled  with  fat,  and  free  masses  of  fat. 

If  the  child  is  dead,  we  have,  of  course,  no  fetal  sounds  or  move- 
ments; but  the  history  and  other  signs  of  pregnancy  remain,  and.the 
fetus  can  be  felt. 

Extra-uterine  pregnancy  rarely  advances  so  far  as  to  form  a  large 
abdominal  tumor.  We  have  the  history  and  the  signs,  not  only  of 
pregnancy,  but  of  ectopic  gestation  (p.  597),  and  the  fetus  is  even  felt 
more  easily  than  in  intra-uterine  pregnancy. 

2.  A  hydatiform  mole  may  be  very  like  an  ovarian  cyst,  but  it 
differs  from  it  by  the  condition  of  the  cervix  during  pregnancy,  the 
contractility  of  the  uterus,  and  the  discharge  of  a  bloody  fluid  con- 
taining debris  of  the  vesicles  of  the  chorion. 

3.  Hematometra,  hydrometra  and  physometra  (p.  421)  are  all  sit- 
uated in  the  uterus,  follow  atresia  of  the  genital  canal,  give  rise  to- 
menstrual  molimina,  and  do  not  affect  the  constitution. 

4.  Sessile  fibroids  are  hard,  nodular,  and  situated  in  the  wall  of  the- 
uterus.     Pediculated  fibroids  may  be  much  like  an  ovarian  cyst,  but 
are  harder. 

Fibrocystic  tumors  of  the  uterus  may  be  so  like  multilocular,  colloid,, 
sessile  ovarian  cysts  that  the  most  experienced  gynecologists  may  be 
deceived  in  differentiating  them.  The  points  to  keep  in  mind  are  that 
fibrocysts  are  rare,  that  they  usually  appear  in  persons  over  thirty 
years  of  age,  that  the  uterine  cavity  commonly  is  considerably  enlarged, 
that  the  tumor,  as  a  rule,  forms  one  mass  with  the  uterus,  that  it* 
consistency  is  harder,  that  hard  masses  are  often  felt  in  the  upper  part 
of  the  tumor,  that  the  patient  often  suffers  from  profuse  menorrhagia, 
that  the  development  is  slow,  and  that  the  constitution  suffers  less. 

If  the  fluid  coagulates  spontaneously,  rapidly,  and  in  toto,  it  is  proof 
that  the  tumor  is  a  fibrocyst. 


DISEASES  OF  THE  OVARIES. 


599 


5.  Ascites. — The  abdomen  appears  flat,  and  no  tumor  is  felt.  The 
fluctuation  is  very  marked.  The  percussion  is  tympanitic  on  the  part 
of  the  abdomen  turned  upward,  and  dull  in  the  dependent  parts  in 
whatever  position  we  place  the  patient.  In  Fig.  318  the  shaded 


FIG.  318. 


Percussion-sound  in  Ascites  to  the  left  and  in  Ovarian  Cyst  to  the  right  when  the  patient 
lies  on  her  back  (Spencer  Wells). 

parts  mark  the  dull  percussion.  The  fluid  is  not  viscid,  forms  a  small 
coagulum  by  exposure  to  the  air,  and  contains  flat  endothelial  cells  and 
lymph-corpuscles  with  ameboid  movements.  As  a  rule,  the  condition 
is  found  to  be  due  to  diseases  of  the  liver,  heart  or  kidneys. 

If  the  ascitic  collection  is  so  enormous  as  to  distend  the  whole 
abdomen,  it  may,  however,  be  impossible  to  elicit  the  above-described 
signs ;  but  then  such  a  mass  of  fluid  may  accumulate  in  the  00111*86 
of  a  few  months  in  ascites,  while  an  ovarian  cyst  takes  years  to  grow 
to  such  enormous  proportions.  The  uterus  is  easily  movable  in  ascites, 
immovable  in  cases  of  very  large  cysts. 

6.  Hematocele  (see  above  under  Pelvic  Tumor). 

7.  Encysted  peritonitic  exudation  gives  a  history  of  inflammation. 
The  fluid  is  serous,  like  that  in  ascites. 

8.  Tuberculosis  of  the  peritoneum  is  accompanied  by  free  fluid,  and 
often  by  a  tumor  formed  by  agglutinated  intestinal    knuckles  and 
omentum,  that  may  be  hard  to  differentiate  from  an  ovarian  cyst. 
These   pseudotumors,   however,  are  much  more  common  in  young 
women  than  later  in  life,  and  grow  much  more  rapidly  than  ovarian 
cysts.   Sometimes  the  central  part  of  the  abdominal  wall  is  the  seat  of 
a  red  blush  and  edema.    The  fluid  is  straw-colored,  and  coagulates,  at 
least  partially,  by  exposure  to  the  air.     The  presence  of  tubercles  in 
the  lungs,  pleurisy,  great  tenderness,  on  pressure,  of  the  intestines,  and 
a  rise  in  temperature  in  the  evening,  also  go  far  to  establish  the  diagno- 


600  DISEASES  OF  WOMEN. 

sis  of  tuberculosis  of  the  peritoneum  ;  and  as  laparotomy  has  proved  a 
cure  for  this  disease,  no  harm  is  done,  if  a  mistake  should  be  made.1 

9.  Cancer  of  the  peritoneum  is  accompanied  by  rapid  cachexia. 
The  fluid  often  contains  characteristic  cells  (p.  513).     Large,  hard, 
irregular  masses  can  be  felt  in  the  abdominal  cavity. 

10.  Oysts  of  the  broad  ligament  are  much  rarer  than  ovarian  cysts, 
seldom  larger  than  an  adult's  head,  immovable,  and  dip  deep  into  the 
pelvis,  where  they  are  situated  close  up  to  the  uterus.     As  a  rule, 
they  develop  slowly.     The  fluid  is  as  described  above  under  Pelvic 
Tumor.     When  evacuated,  the  tumor  is  slow  to  refill. 

11.  Omental  cysts  are  situated  higher  up  in  the  abdomen,  and  have 
no  connection  with  the  pelvic  organs.     The  fluid  is  serous  like  that 
of  ascites. 

There  may  also  be  a  solid  tumor  of  the  omentum,  especially  a  carci- 
nomatous  tumor. 

12.  Hydronephrosis  lies  behind  the  intestine,  and  occupies  a  more 
lateral  position.    There  is  a  history  of  urinary  trouble.    The  fluid  may 
contain  columnar  epithelial  cells  and  a  large  amount  of  urea,  but  is 
very  unreliable,  and  even  deceptive.     Perhaps,  it  may  be  reached  by 
means  of  catheterization  of  the  ureter  (p.  165). 

13.  Renal  cysts  are  rare.     There  is  a  tympanitic  percussion-sound, 
because  the  intestine  lies  in  front  of  it.     There  is  a  history  of  urinary 
trouble.    These  cysts  develop  from  above  downward.     Sometimes  the 
peculiar  shape  of  the  kidney  can  be  recognized.      The  fluid  con- 
tains much  urea. 

14.  A  floating  kidney  or  one  fastened  in  the  iliac  fossa  has  also 
been  mistaken  for  an  ovarian  cyst.     In  this  case  the  characteristic 
shape  is  still  better  preserved  than  when  the  organ  is  the  seat  of  cystic 
degeneration. 

15.  A  hydatid  of  the  liver  develops  downward  from  the  right  hypo- 
chondrium,  and  can  be  felt  to  be  continuous  with  the  liver.    The  dull 
percussion-sound  extends  uninterruptedly  to  the  liver  region.     Some- 
times hydatid  vibration  can  be  felt.     The  fluid  is  clear  as  spring- 
water,  does  not  coagulate  by  heat,  and  may  contain  booklets  of  echi- 
nococci  or  shreds  of  cuticula,  the  parallel  striatiou  of  which  is  pathog- 
nomonic.      In  its  chemical  composition  enter  succinic  acid,  leucin, 
grape-sugar,  and  inosite,  but  never  paralbumin.      (Hydatids  of  the 
Pehns  will  be  described  in  Part  vii.,  Chap.  ix). 

16.  Liver-cysts,  other  than   hydatid   cysts,  are   exceedingly  rare. 
They  develop  from  the  right  hypochondrium.     The  fluid  may  con- 
tain bile  or  liver-cells,  and  does  not  contain  the  bodies  usually  found 
in  ovarian  tumors. 

17.  A  floating  liver  is  recognized  by  its  shape,  the  clear  percussion 

1  Encysted  tubercular  peritonitis  has  been  lucidly  discussed  by  W.  T.  Howard  of 
Baltimore  in  Trans.  Amer,  Oyn.  Soc.,  1885,  vol.  x.  pp.  41-62. 


DISPOSES  OF  THE  OVARIES.  601 

in  the  liver  region,  and  the  possibility  of  replacing  the  liver  in  its 
normal  position. 

18.  Pancreas-cysts  are  rare  and  develop  downward.     The  fluid  is 
acid  and  contains  small  nuclei  and  peculiar  thready  bodies.1 

19.  Cysts  of  the  spleen  are  very  rare,  develop  from  the  left  hypo- 
chondrium,  and  the  fluid  is  rich  in  leucocytes. 

Solid  splenic  tumors  retain  the  peculiar  shape  of  the  spleen,  and  are 
harder. 

All  tumors  coming  from  above  leave  for  a  time  a  resonant  space 
above  the  symphysis.  The  production  of  gas  in  the  stomach  and  in- 
jection of  water  into  the  intestine  drive  a  tumor  in  the  direction 
from  which  it  has  started  (p.  158). 

20.  Cysts  of  the  mesentery  are  very  rare.     Perhaps  both  ovaries  can 
be  felt.     The  tumor  is  sometimes  freely  movable  in  an  upward  direc- 
tion.    A  kind  of  pedicle  formed  by  the  mesentery  may  extend  to  it 
from  above.     The  fluid  is  serous,  without  epithelial  cells. 

21.  Cysts  of  the  abdominal  wall  have  no  connection  with  the  uterus. 
The  fluid  is  serous,  and  does  not  contain  cellular  elements. 

Cysts  of  the  urachus  contain  flat  epithelial  cells. 

22.  A  solid  tumor  of  the  abdominal  wall,  especially  a  fibroma  of 
the  fascia  transversalis  with   partial  cystic   degeneration,  has  been 
taken  for  an  ovarian  cyst.2     The  lack  of  menstrual  disturbance  and 
of  pain  may  give  rise  to  a  doubt,  which  may  be  cleared  by  examina- 
tion under  ether. 

A  thick  layer  of  subcutaneous  adipose  tissue  has  given  rise  to  the 
same  mistake,  but  it  may  be  raised  between  the  fingers,  and  on  deep 
percussion  we  get  a  clear  sound. 

Edema  of  the  anterior  wall  is  characterized  by  the  pitting  left  by 
pressure. 

23.  Hydrosalpinx  very  seldom  forms  a  large  tumor  (p.  544).     It 
is,  as  a  rule,  bilateral,  always  monocystic,  and  not  very  tender.     The 
fluid  is  serous,  and  does  not  contain  the  bodies  commonly  found  in 
ovarian  tumors.     The  presence  of  ciliated  columnar  epithelial  cells 
does  not  decide  the  question  (p.  580). 

24.  Spina  bifida  very  rarely  forms  a  tumor  in  the  pelvis  and  abdo- 
men, but  in  one  case  it  contained  some  three  quarts  of  fluid.3    This  is 
watery,  colorless,  limpid,  without  form-elements,  and  contains  only 
traces  of  albumin.     After  evacuation  of  the  fluid  the  fissure  in  the 
sacrum  through  which  the  cyst  entered  the  pelvis  may  be  felt. 

25.  Dilatation  of  the  Stomach. — Incredible  as  it  may  seem,  even  a 
dilated  stomach  has  been  mistaken  for  an  ovarian  cyst  and  operated 

1  Garrigues,  Diagnosis,  p.  86. 

J  An  interesting  case  of  the  kind  was  reported  by  Rob.  Weir,  in  the  Med.  Record, 
Dec.  3,  1887,  xxxiii.  703. 
3  Emmet,  Gynecology,  2d  ed.  p.  791. 


602  DISEASES  OF  WOMEN. 

on.1  The  chief  points  which  are  to  be  borne  in  mind  in  order  to 
avoid  a  similar  mistake  are  the  great  variations  in  the  size  of  the 
tumor ;  the  change  in  the  distribution  of  the  tympanitic  and  the  dull 
percussion-sound,  according  to  the  presence  of  gas  or  food  in  the 
stomach ;  and  the  large  quantities  of  food  vomited  at  times,  rep- 
resenting nearly  all  that  has  been  ingested  for  several  days.  Once 
on  the  alert,  the  diagnosis  can  be  made  clear  by  the  introduction  of 
an  esophageal  sound  or  the  production  of  gas  in  the  stomach  (p.  158), 

26.  Distention  of  the  Bladder. — A  bladder  may  be  overdistended 
with  urine  although  the  patient  urinates  (ischuria  paradoxa),  and 
may  form  a  very  large  tumor  in  the  abdomen.2     Before  making  his 
examination  the  doctor  should,  therefore,  introduce  the  catheter,  and 
empty  the  bladder. 

27.  Impaction  of  Feces. — A  patient  may  likewise  suffer  from  diar- 
rhea, and  still  carry  large  masses  of  feces  in  her  intestines,  which 
may  be  mistaken  for  tumors.     Before  a  diagnosis  is  made,  the  bowels 
should  be  emptied  with  aperient  medicines  and  large  irritating  enemas 
(p.  174). 

28.  Tympanites  gives  tympanitic  percussion-sound. 

29.  A  phantom  tumor  is  a  curious  condition  sometimes  met  with  in 
hysterical  patients  and  in  those  affected  with  caries  of  the  vertebra?. 
Through  a  combination  of  adipose  tissue  in  the  wall  and  tetanic  con- 
traction of  the  abdominal  muscles  a  protuberance  is  formed  on  the 
abdomen,  which  even  may  give  a  somewhat  dull  percussion-sound. 
The  moment  the  patient  is  anesthetized  the  supposititious  tumor  sub- 
sides and  disappears,  leaving  an  area  yielding  the  normal  tympauitic 
sound  of  the  intestine. 

Large  extraperitoneal  ovarian  cysts  are  particularly  difficult  ta 
diagnosticate.  They  have  no  pedicle. 

Other  signs,  that,  taken  conjointly  and  not  singly,  may  give  rise 
to  a  more  or  less  strong  suspicion  of  the  existence  of  this  kind  of  cyst, 
are  the  following :  1,  close  adherence  to  the  enlarged  and  laterally 
displaced  uterus;  2,  elongation  of  the  bladder,  as  proved  by  the 
introduction  of  a  steel  sound ;  3,  pressure  on  the  rectum  and  bulging 
out  of  the  posterior  vaginal  cul-de-sac;  4,  embarrassed  defecation 
and  micturition  ;  5,  spontaneous  rupture  of  the  cyst ;  6,  unusual  pain 
caused  by  the  growing  cyst ;  7,  tympanitic  percussion-sound  in  front 
of  the  tumor,  like  that  found  in  renal  tumors;  8,  an  unsymmetrical 
shape  and  preponderating  development  in  one  side  of  the  pelvis  of  a 
firmly  fixed  cyst.3 

Complications. — Ovarian  cysts  may  be  complicated  by  many  dis- 
eases, some  of  which  may  be  directly  referable  to  the  pressure 

1  Beeves  Jackson,  Detroit  Lancet,  1880 ;  Centralblatt.  fir  Gynak.,  1880,  vol.  iv.  p.  368. 

2  I  have  myself  withdrawn  three  quarts  of  urine  from  the  bladder. 
8  \Vm.  Goodell,  Amer.  Syst.  of  Gynecol.,  vol.  ii.  p.  830. 


DISEASES  OF  THE  OVARIES.  603 

exercised  by  the  tumor  itself,  while  others  are  mere  coincidences, 
which,  however,  may  have  considerable  influence  on  the  prognosis 
and  treatment.  Thus  we  would  not  perform  ovariotomy,  if  the  cyst 
is  accompanied  by  cancer  of  the  uterus,  unless  the  latter  organs  could  be 
extirpated  at  the  same  time — an  addition  to  the  operation  which,  of 
course,  would  cast  a  deep  shadow  over  the  prognosis.  In  advanced 
tuberculosis  or  any  other  serious  chronic  disease  it  may  also  be  deemed 
inadvisable  to  subject  the  patient  to  the  risks  of  a  capital  operation, 
which  at  best  will  fail  to  prolong  her  life. 

The  complication  with  pregnancy  is  of  particular  interest,  since  it 
is  not  so  very  rare,  and  may  influence  the  treatment  very  much.  It 
may  occur  even  when  both  ovaries  form  large  tumors,  and  so  much 
the  more  so  when  only  one  is  affected.  The  diagnosis  is  made  from 
the  history  and  the  objective  find,  the  presence  of  an  ovarian  tumor 
having  been  known  before  the  patient  became  pregnant,  or  being 
made  out  in  connection  with  the  gravid  uterus.  When  the  pres- 
ence of  one  child  is  ascertained,  the  investigation  must  next  be  di- 
rected toward  the  second  mass,  with  a  view  to  decide  whether  the  case 
is  simply  one  of  twins  or  of  uterogestation  combined  with  a  tumor. 

The  simultaneous  pressure  of  a  growing  uterus  and  an  ovarian  cyst 
will  in  most  cases  cause  so  much  discomfort,  or  even  be  attended  with 
such  danger,  that  interference  is  called  for.  Three  methods  are  then 
at  our  disposal :  1,  artificial  abortion  or  premature  labor;  2,  tapping 
of  the  cyst ;  or,  3,  ovariotomy.  If  possible,  we  would  wait  till  the 
child  is  viable,  and  then  induce  premature  labor.  Tapping  has  given 
excellent  results,  and  there  is  no  serious  objection  to  it,  if  performed 
by  a  man  prepared  to  let  ovariotomy  follow  if  untoward  sequences 
should  develop.  Ovariotomy  has  been  performed  many  times  during 
pregnancy.  The  dangers  of  the  operation  are  very  slightly  increased, 
but  sometimes  it  is  followed  by  abortion. 

Prognosis. — A  spontaneous  cure  of  an  ovarian  cyst  may  take 
place  by  means  of  slow  torsion  of  the  pedicle,  followed  by  atrophy, 
fatty  degeneration,  or  calcification.  Or  it  may  be  brought  on  by 
rupture  of  the  cyst.  The  tumor  may  also  shrivel  up  after  one  or 
more  tappings.  It  may  also  become  stationary  and  stop  growing. 
But  all  these  occurrences  are  so  rare,  that  they  must  be  left  entirely 
out  of  consideration  when  the  question  of  treatment  is  raised. 

A  patient  may  live  twenty  years  with  an  ovarian  cyst,  but  in  the 
vast  majority  of  cases  a  speedy  death  awaits  the  woman  affected  with  such 
a  tumor.  Of  those  having  a  proliferating  cystoma,  60  to  70  per  cent. 
die  within  three  years,  and  10  per  cent,  additional  in  the  fourth  year. 

Treatment. — Medical  treatment  is  of  no  avail,  and  galvanopuncture 
is  more  dangerous  than  ovariotomy.  Noeggerath  *  claims  that  a 

1  E.  Noeggerath,  Centralblf.  Gynak.,  1890,  vol.  xiv.,  "Report  of  Tenth  Inter- 
national Congress,"  p.  86. 


604  DLSEASES  OF  WOMEN. 

•weak  faradic  cwrent  applied  three  times  a  week  for  from  one-half  to 
one  hour  makes  a  glandular  proliferating  ovarian  tumor  of  small  or 
medium  size  disappear  in  six  to  eight  weeks,  so  that  only  small  rem- 
nants of  it  remain.  He  uses  the  secondary  current,  the  negative 
pole,  covered  with  a  sponge,  in  the  vagina,  the  positive,  in  the  shape 
of  a  sponge-covered  plate  of  the  size  of  a  hand,  on  the  abdomen.  As 
the  procedure  is  innocuous,  it  might  be  tried. 

Two  kinds  of  treatment  only  are  generally  recognized — namely, 
tapping  and  ovariotomy;  and  it  maybe  stated  from  the  beginning 
that  ovariotomy  should  be  performed  whenever  it  is  practicable. 

Tapping. 

Tapping  as  a  therapeutic  measure  is  objectionable  for  several 
reasons.  It  may  cause  hemorrhage,  a  danger  which,  however,  is  con- 
siderably reduced  by  using  a  fine  needle  or  trocar  and  canula  con- 
nected with  an  aspirator.  It  may  cause  suppuration  of  the  cyst ;  but 
that  may  be  entirely  obviated  by  using  a  clean  instrument,  and 
disinfecting  the  patient's  skin  and  the  operator's  hands  carefully. 
Acrid  fluid  may  find  its  way  through  the  opening  in  the  cyst  into  the 
peritoneal  cavity,  and  set  up  peritonitis.  This  may  also,  to  a  great  ex- 
tent, be  prevented  by  emptying  the  opened  cavity  entirely ;  but  nobody 
ought  to  tap  without  being  prepared  to  have  an  ovariotomy  follow  in 
case  of  supervening  peritonitis.  A  malignant  infection  of  the  peri- 
toneum may  take  place,  if  the  tumor  happens  to  be  of  the  papillary 
variety,  and  particles  of  the  papillomatous  growths  are  carried  out  into 
the  peritoneal  cavity  on  withdrawing  the  instrument.  As  nearly  all 
ovarian  cysts  contain  secondary  cysts,  these  will,  on  removal  of  the 
pressure  from  the  emptied  compartment,  only  develop  so  much  the 
faster.  The  tapping  has  to  be  repeated  again  and  again,  with  ever 
shorter  intervals,  thus  constituting  a  serious  drain  on  the  strength  of 
the  patient.  The  sudden  evacuation  of  a  large  amount  of  fluid  may 
so  change  the  shape  of  the  tumor  that  a  rotation  is  induced,  accom- 
panied by  torsion  of  the  pedicle  (p.  584). 

In  spite  of  all  real  and  imaginary  dangers  connected  with  tapping, 
there  are,  however,  circumstances  under  which  it  is  perfectly  proper 
to  have  recourse  to  it : 

1.  If  a  patient  absolutely  refuses  to  have  ovariotomy  performed, 
tapping  may  yet  offer  relief,  and  sometimes  even  prolong  her  life. 

2.  We  have  seen  above  (p.  603)  that  during  pregnancy  tapping  has 
in  many  cases  given  excellent  results  as  a  palliative  measure.     If  the 
physician  is  first  called  during  actual  labor,  and  the  cyst  offers  an 
obstruction  to  its  progress,  tapping  is  in  many  instances  preferable  to 
any  other  treatment. 

3.  The  removal  of  very  large  tumors  has  been  attended  by  sudden 
death  on  account  of  anemia  of  the  brain  caused  by  the  rush  of  blood 


DISEASES  OF  THE   OVARIES. 


605 


to  the  abdominal  organs  at  the  cessation  of  the  pressure  exercised  on 

them  by  the  tumor.     Other  vital  organs,  such  as  the  heart,  the  lungs, 

and  the  kidneys,  may  be  so  compressed  by  the  cyst  that  they  are  not 

in  a  condition  to  perform  their  functions  properly.     It 

is,  under  such  circumstances,  a  good  plan   to  prepare       FIG.  319. 

the  system  for  the  radical  operation  by  the  preliminary 

slow  evacuation  of  some  of  the  fluid  contained  in  the 

cyst. 

4.  Tapping  may  be  indicated  by  the  presence  of  an 
acute  disease,  such  as  pneumonia,  bronchitis,  typhoid 
fever,  smallpox,  etc.,  which  makes  it  desirable  to  re- 
move pressure,  but  excludes  the  immediate  perform- 
ance of  ovariotomy. 

5.  It  is  also  indicated  in  advanced  chronic  diseases, 
such  as  tuberculosis,  Bright's  disease,  and  cancer. 

6.  Finally,  in  the  rare  cases  in  which  ovariotomy  is 
impossible. 

Tapping  may  be  performed  through  the  abdominal 
wall  or  through  the  posterior  vault  of  the  vagina.  It 
may  be  performed  with  a  large  trocar,  such  as  that 
used  for  ascites,  or  by  means  of  an  aspirator.  The 
former  is  more  expeditious,  and,  if  the  fluid  is  thick,  the 
only  available  method ;  the  latter  is  considerably  safer. 
If  a  large  trocar  is  used,  it  is  well  to  prevent  the  possible 
entrance  of  air  by  having  a  soft-rubber  tube  attached  to 
it,  the  other  end  of  which  is  kept  under  the  surface 
of  some  fluid  in  the  receptacle.  The  instrument  repre- 
sented in  Fig.  319  offers  the  further  advantage  that, 
in  case  of  obstruction  of  the  canula,  the  trocar  can  be 
pushed  forward  again. 

Modus  Operandi. — The  patient  should  lie  on   her 
back.     The  puncture  is  usually  made  in  the  median 
line,   midway   between  the   symphysis  pubis  and  the 
umbilicus.     With  a   hypodermic    injection  of  cocaine 
(p.  209)  the  skin  may  be  made  insensible,  and  a  small 
longitudinal  incision,  large  enough  to  admit  the  trocar, 
be  made  through  it,  which  leaves  a  better  wound  for 
healing  than  if  the  trocar  is  thrust  through  the  skin. 
If  an  aspirator  is  used,  the  pain  is  so  insignificant  and 
the  opening   so   small    that   neither   cocaine   nor   the 
cutaneous  incision  is  called  for.     If  the  canula  becomes      iT0cr 
blocked  up  during  the  flow  of  the  fluid,  a  disinfected 
stylet  should  be  used  to  clear  it  without  removing  it.    Sometimes  the 
obstruction  is  due  to  contact  with  the  inside  of  the  cyst-wall,  and  is 
overcome  by  changing  the  direction  of  the  canula.    It  is  risky  to  open 


606  DISEASES  OF   WOMEN. 

more  than  one  cyst  at  a  time,  as  large  blood-vessels  may  run  in  the 
deeper  parts  of  the  cyst.  After  the  operation  the  wound  is  closed,  the 
abdomen  covered  with  a  thick  pad  of  cotton,  and  surrounded  with  a 
binder,  so  as  to  counteract  the  loss  of  pressure  caused  by  the  removal 
of  the  fluid.  If  there  is  any  bleeding,  which  is  very  rare,  a  hare-lip 
pin  may  be  passed  deep  in  under  the  lips  of  the  wound  and  surrounded 
by  a  figure-of-eight  ligature.  The  patient  should  be  kept  in  bed  for 
four  days.  (For  further  particulars  see  p.  159.) 

Tapping  through  the  vagina  is  much  more  hazardous,  and  likely  to 
give  less  relief,  since  the  large  compartments  of  a  cyst  are  found  in 
the  abdominal  part  of  an  ovarian  cyst.  If  the  operation  is  followed 
by  suppuration,  ovariotomy  must  be  performed  or  the  opening  in  the 
vagina  and  cyst  enlarged  by  incision,  so  as  to  make  room  for  a 
T-shaped  soft-rubber  drainage-tube,  through  which  disinfectant  fluid 
should  be  injected  daily,  until  the  discharge  ceases. 

Ovariotomy. 

Ovariotomy  is  the  operation  by  which  an  ovarian  tumor  is  re- 
moved from  the  body,  while  the  term  oophorectomy  is  used  to  desig- 
nate the  removal  of  ovaries  which  do  not  exceed  the  normal  size  of 
the  organ  very  much  (p.  559). 

Indications  and  Contraindications. — In  a  general  way  it  may  be 
said  that  ovariotomy  is  indicated  in  every  case  of  ovarian  cyst,  and 
as  soon  as  its  presence  is  discovered. 

Small  tumors  may  be  more  difficult  to  remove  because  the  pedicle 
is  less  developed,  but,  on  the  other  hand,  there  is  less  danger  from 
adhesions.  The  patient  is  spared  all  the  accidents  to  which  such 
tumors  are  liable  in  the  course  of  their  development  (pp.  593-95). 
Finally,  we  must  take  into  consideration  the  pronounced  tendency 
ovarian  tumors  have  to  become  malignant  (p.  586). 

Special  indications  for  immediate  operation  are  serious  hemorrhage 
into  the  cyst,  suppuration  of  the  cyst,  torsion  of  the  pedicle,  rupture 
into  the  peritoneal  cavity  followed  by  alarming  symptoms,  and  the 
occurrence  of  peritonitis  or  of  intestinal  obstruction. 

The  age  of  the  patient  need  not  be  taken  into  consideration  :  ova- 
riotomy has  been  performed  with  success  in  young  children  and  in  old 
women  over  eighty  years  of  age. 

Even  hemophilia  is  no  contraindication,  since  the  operation  has 
been  successfully  performed  under  such  circumstances. 

On  the  other  hand,  the  surgeon  should  abstain  from  so  capital  an 
operation,  if  the  patient  is  in  an  advanced  stage  of  tuberculosis  or 
ohronic  nephritis  or  suffers  from  cancer  in  any  other  organ  than  the 
ovary,  unless  the  cancer  can  be  removed  at  the  same  time  or  by  a 
separate  operation.  Cancer  in  the  ovarian  cyst  itself  also  forms  a 


DISEASES  OF  THE   OVARIES.  607 

contraindication,  if  the  disease  has  invaded  the  surroundings  or  in- 
'fected  the  constitution.  The  same  applies  to  any  other  wasting  dis- 
ease that  may  be  expected  soon  to  put  an  end  to  the  patient's  life. 

Ovariotomy  may  be  performed  through  the  abdominal  wall  or 
through  the  vagina,  the  former  of  which  methods  is  by  far  the  more 
common  and  important. 

Vaginal  ovariotomy  should  be  limited  to  cases  of  small,  especially 
freely  movable  cysts.  The  drawbacks  in  entering  the  abdomen  from 
the  vagina  have  been  set  forth  in  speaking  of  oophorectomy  (p.  540), 
and  the  great  frequency  of  adhesions  of  ovarian  cysts  recommends 
particularly  the  abdominal  section  for  tumors  that  have  risen  into  the 
abdomen.  Small  cysts  behind  the  broad  ligaments  may  be  removed 
by  posterior  colpotomy,  but  small  intraligamentous  cysts  are  best 
reached  through  anterior  colpotomy  (p.  450). 

In  the  following  we  consider  only  abdominal  ovariotomy. 
Preparatory  Treatment. — If  the  patient  is  weak,  and  has  been  living 
in  unfavorable  circumstances  as  to  food  and  shelter,  it  is  advisable  to 
give  her  a  chance  of  gaining  in  health  and  strength  by  proper  diet 
and  regimen.  Under  all  circumstances  the  skin  is  cleaned,  the  bowels 
are  emptied,  and,  if  necessary,  the  functions  of  the  kidneys  regulated 
(p.  196). 

Some  surgeons  give  ten  grains  of  quinine  for  several  days  in  order 
to  ward  oif  fever,  which,  however,  is  hardly  necessary,  unless  the  patient 
is  subject  to  malaria.  Others  praise  bromides  as  a  preventive  of  vom- 
iting. 

In  regard  to  season,  the  time  of  the  day,  menstruation,  lactation, 
the  arrangement  of  the  room  and  table,  the  presence  of  spectators,  the 
administration  of  the  anesthetic,  the  patient's  dress,  and  disinfection, 
the  reader  is  referred  to  what  has  been  said  in  speaking  of  operations 
in  general  (pp.  192-224). 

Instruments,  Sponges,  etc. — In  a  simple  ovariotomy  very  few  instru- 
ments are  required ;  but,  as  it  is  impossible  to  foretell  with  certainty 
what  difficulties  may  arise,  a  rather  large  armamentarium  must  be 
prepared  to  overcome  them.  The  following  paraphernalia  ought  to 
be  within  reach : 

4  large  flat  sponges ; 

4  large  round  sponges ; 

8  small  round  sponges  (p.  200 ;  about  the  substitution  of  gauze, 
see  p.  201) ; 

4  sponge-holders  (Fig.  183,  p.  213)  or  forceps; 

1  sharp-pointed  bistoury ; 

1  probe-pointed  bistoury ; 

1  pair  of  long  straight  blunt-pointed  scissors ; 

1  pair  of  blunt-pointed  scissors  curved  on  the  flat ; 

1  dissecting-forceps ; 


608  DISEASES  OF  WOMEN. 

1  mouse-tooth  thumb-forceps ; 

1  director ; 

12  pairs  of  small  pressure-forceps  (Fig.  157,  p.  184); 
3  pairs  of  small  pressure-forceps  with  T-shaped  jaws ; 
6  pairs  of  long  pressure-forceps  (Fig.  267,  p.  485); 

2  pairs  of  Nelaton's  cyst-forceps  (Fig.  321,  p.  612) ; 
2  volsella  (Fig.  180,  p.  212)  ; 

2  pairs  of  Spencer  Wells's  pedicle-forceps  (Fig.  322,  p.  613) ; 
1  male  metal  catheter ; 
1  female  metal  catheter  ; 

1  male  urethral  steel  sound,  No.  25  French ; 

2  small  tenacula  (Fig.  180,  p.  212) ; 

1  Simon's  sharp  spoon  (Fig.  133,  p.  154); 
1  tenaculum-forceps ; 
1  large  curved  trocar  (Fig.  320,  p.  612) ; 
1  small  curved  trocar  (Fig.  164,  p.  190); 

1  aspirator  (Fig.  138,  p.  160) ; 

2  retractors ; 

1  cautery-clamp  (Fig.  323,  p.  613) ; 

1  thermo-cautery  (Fig.  156,  p.  183); 

1  yard  of  rubber  cord  for  temporary  compression ; 

drainage-tubes  of  glass  and  soft  rubber,  one  of  the  latter  T-shaped ; 

1  uterine  sound  ; 

1  dull  handled  needle  (Fig.  185a,  p.  215) ; 

1  Schroeder's  needle,  bent  at  right  angles  (Fig.  269,  p.  487) ; 

1  Folk's  needle  (Fig.  270,  p.  487) ; 

2  strong  curved  Hagedorn  needles  for  closing  incision ; 
2  smaller  curved  needles  for  passing  ligatures ; 

2  fine  curved  needles ; 
6  cambric  needles  for  the  intestine ; 
1  Hagedorn  needle-holder; 
1  common  needle-holder; 

Silk  for  ligatures  and  sutures,  fine,  medium,  and  strong ; 
Catgut ; 
Silkworm  gut. 

A  movable  electric  lamp  is  sometimes  very  useful ; 
For  dressing :  lodoform ; 

lodoform  gauze ; 

Gutta-percha  tissue ; 

Salicylated,  borated,  or  plain  aseptic  absorbent  cotton ; 

Rubber  adhesive  plaster ; 

Flannel  binder  or  many-tailed  muslin  bandage ; 

6  large  safety-pins. 

Ovariotomy  begins  with  laparotomy. 


DISEASES  OF  THE  OVARIES.  609 

Laparotomy,1  or  abdominal  section,  is  an  operation  consisting  in  an 
incision  through  the  abdominal  wall  into  the  peritoneal  cavity.  In 
ovariotomy  the  chief  steps  are — 

1,  the  abdominal  incision  ; 

2,  the  removal  of  the  cyst ; 

3,  the  closure  of  the  wound ; 

4,  the  dressing. 

With  few  exceptions  laparotomy  is  performed  in  the  median  line, 
between  the  umbilicus  and  the  symphysis  pubis.  According  to  dif- 
ferent circumstances  the  incision  is  made  longer  or  shorter,  more  or 
less  near  the  symphysis,  and  may  be  extended  beyond  the  umbilicus 
all  the  way  up  to  the  ensiform  process. 

The  patient  is  placed  on  her  back,  extended  at  full  length  on  a  table, 
with  her  feet  toward  the  window.  The  necessary  preparations  have 
been  described  in  the  general  division  (pp.  193-224).  The  operator 
stands  on  the  right  side.  At  least  one  assistant  besides  the  one  who  gives 
the  anesthetic  is  needed,  and  stands  on  the  left  side  of  the  patient,  facing 
the  operator.  Many  operators  prefer,  in  order  to  avoid  sources  of 
infection,  to  have  as  little  assistance  as  possible,  and  take  the  instru- 
ments from  the  tray  themselves. 

For  operations  in  the  pelvis  Trendelenburg's  position  (p.  138)  offers 
great  advantages,  the  organs  being  more  exposed  to  view  and  easier 
to  reach.  For  this  position  the  patient  is  turned  with  the  head  toward 
the  light.  The  operator  may  stand  on  her  right,  which  affords  him 
better  light,  if  the  light  comes  from  the  side  only,  but  has  the  draw- 
back that  he  must  lift  his  arm  in  a  somewhat  fatiguing  way ;  or  he 
may  stand  on  her  left.  Often  he  has  to  change  his  position  from  one 
side  to  the  other,  the  principle  being  that,  when  there  is  any  trouble, 
he  must  stand  on  the  opposite  side  to  the  one  where  he  wants  to  see. 

Plan's  Position. — Some  surgeons  prefer  to  operate  sitting,  which 
becomes  a  necessity  in  very  protracted  operations.  Pean  has  con- 

1  Dr.  Robert  P.  Harris  of  Philadelphia  published  in  1890  a  pamphlet  entitled 
"  Ooeliotomy.  This,  and  not  laparotomy,  is  the  proper  Greek  synonym  of  ' abdominal 
section?  laparotomy  being  an  incision  of  the  flank  only."  Unfortunately  this  name  has 
been  adopted  to  some  extent. 

First,  it  is  to  be  regretted  that  the  euphonious  word  laparotomy,  with  its  beautiful 
liquids  and  open  vowels,  should  be  driven  out  by  "celiotomy" — for  that  is  not  only 
the  pronunciation,  but  the  modern  spelling — with  its  sharp  sibilant  and  thin  sound 
of  e.  Secondly,  when  a  word  has  existed  for  nearly  a  hundred  years,  has  passed  into 
all  languages,  and  forms  the  root  of  numerous  derivatives  and  part  of  compound 
words,  it  causes  only  confusion  to  substitute  another  for  it.  Finally,  even  the  argu- 
ment drawn  from  philology  in  favor  of  the  new  word,  is  to  say  the  least,  doubtful. 
If  it  must  be  admitted  that  rj  ^anapa  means  the  soft  part  between  the  ribs  and  the 
crest  of  the  ilium,  it  is  only  a  very  slight  extension  to  apply  it  to  the  whole  abdominal 
wall,  and  it  has  no  other  sense;  whereas  77  KOIAIU  means,  1,  the  abdominal  cavity; 
2,  the  stomach ;  3,  stools;  4,  the  pulp  of  the  finger ;  5,  any  cavity  ;  and  consequently 
the  word  celiotomy  does  not  convey  even  approximately  an  idea  of  what  is  going  to 
be  cut. 

.    39 


610  DISEASES  OF  WOMEN. 

structed  a  special  table  for  this  purpose.  The  operator  sits  between 
the  patient's  legs,  which  rest  in  movable  hollow  supports  or  hang 
down  over  the  operator's  own  thighs.  For  this  position  the  operator 
sits  on  a  high  chair,  and  the  patient  lies  on  a  low  table,  so  that  he 
can  bend  over  the  abdomen,  and  look  into  the  peritoneal  cavity. 

Behind  and  to  the  left  of  the  operator  is  the  instrument  table ;  to 
the  right,  a  basin  with  corrosive-sublimate  solution  (1  :  2000),  and 
another  with  plain  boiled  water. 

I.  Incision. — In  many  laparotomies  it  suffices  to  make  an  opening 
large  enough  to  admit  the  index-  and  middle  fingers.  If  Trendelen- 
burg's  position  is  to  be  used,  a  much  larger  incision  is  needed.  In 
order  to  inspect  the  pelvic  cavity,  an  incision  extending  from  the  sym- 
physis  pubis  to  the  umbilicus  is  required.  The  first  incision  is  made 
with  a  medium-sized  scalpel  through  the  skin  and  subcutaneous  tissue. 
Bleeding  vessels  are  secured  with  pressure-forceps.  The  next  incision 
severs  the  linea  alba.  If  the  operator  misses  it  and  goes  a  little  out 
to  one  of  the  sides,  no  harm  is  done.  The  only  difference  is  that  he 
will  see  and  perhaps  cut  through  the  inner  fibers  of  the  pyramidalis 
or  rectus  muscle.  The  septum  between  the  two  recti  is,  however, 
easily  found  by  pushing  a  director  from  the  opening  made  in  the 
sheath  to-  the  sides,  a  resistance  being  met  with  in  the  median  line. 

Instead  of  this  incision  in  the  median  line  it  has  been  recommended 
to  make  the  incision  half  an  inch  to  the  side  of  the  median  line, 
whereby  it  is  claimed  that  ventral  hernia  is  avoided.1  I  have  tried 
it  several  times,  but  found  the  adaptation  of  the  edges  less  accurate 
than  with  the  median  incision. 

In  this  part  of  the  operation  there  is  no  danger,  and  it  may  be 
executed  rapidly,  simply  cutting  down  on  the  tissues.  But  under  the 
fascial  and  muscular  tissue  lies  a  layer  of  adipose  tissue,  the  preperi- 
toneal  fat,2  which  forms  an  important  landmark,  for  immediately 
behind  it  is  found  the  peritoneum. 

This  preperitoneal  fat  is,  therefore,  best  torn  with  pressure-forceps 
or  the  handle  of  the  scalpel,  until  the  peritoneum  itself  is  exposed. 

When  the  abdomen  is  distended  by  a  tumor,  its  wall  is  on  the 
stretch,  and  the  tissues  separate  more  easily  than  in  other  laparoto- 
mies, and  in  consequence  of  the  pressure  exercised  on  it  the  preperi- 
toneal fat  may  become  very  much  reduced.  Greater  care  is,  therefore, 
needed  under  these  circumstances  in  making  the  abdominal  incision 
than,  for  instance,  in  oophorectomy,  or  the  operator  risks  plunging 
his  knife  right  into  the  cyst  from  the  start,  not  to  speak  of  wounding 
organs,  such  as  the  omentum,  the  intestine,  or  the  bladder,  that 
might  be  in  the  way. 

1  Abel,  Archiv  fur  Gyndk.,  xlv.  3;  Flatau,  Centralbl.  fur  Qyntik.,  1894,  No.  12,  p. 
278. 
*  It  is  sometimes  called  the  subperitoneal  fat,  an  expression  that  is  apt  to  mislead. 


DISEASES  OF  THE  OVARIES.  611 

The  exposed  peritoneum  is  seized  with  two  pairs  of  pressure-for- 
ceps or  with  a  tenaculum,  and  lifted  up  in  a  fold,  in  which  a  small 
opening  is  cautiously  made  with  the  knife.  Before  doing  this  all  hem- 
orrhage should  be  stopped  by  grasping  bleeding  vessels  with  pressure- 
forceps,  which  are  left  on  during  the  following  steps  of  the  operation, 
until  they  are  in  the  way,  and  bleeding  has  stopped.  Now  the  left 
index-finger  is  introduced,  and  the  knife  held  against  it  and  made  to 
cut  the  peritoneum  from  within  outward  until  the  hole  is  large 
enough.  If  after  a  digital  exploration  the  operator  deems  it  neces- 
sary to  enlarge  the  opening,  it  is  done  with  a  pair  of  strong  straight 
scissors,  one  blade  of  which  is  placed  inside  of  the  abdominal  cavity, 
between  the  middle  and  index-fingers,  which  keep  intestine  and  omen- 
turn  out  of  the  way  and  protect  the  bladder ;  and  the  other  touches 
the  skin.  Thus  the  whole  thickness  of  the  abdominal  wall  is  cut 
through,  and  bleeding  vessels  are  caught  with  pressure-forceps.  As 
to  the  length  of  the  incision,  we  can  only  say  that  it  should  not  be 
longer  than  required,  but  long  enough  to  allow  of  all  necessary 
manipulations.  A  pressure-forceps  is  put  on  the  peritoneum  on  either 
side  of  the  incision,  so  as  to  facilitate  finding  it  again  when  the  wound 
is  to  be  closed.  Instead  of  that,  the  peritoneum  may  be  sutured  to 
the  skin  in  one  or  more  places  on  either  side.  These  sutures  are  tied 
loosely  and  left  long,  so  that  they  may  serve  as  retractors.  In  closing 
the  wound  they  are  gradually  removed  as  they  are  reached  in  insert- 
ing the  permanent  sutures. 

The  lower  end  of  the  incision  ought,  finally,  to  be  half  an  inch 
above  the  symphysis ;  the  upper  varies  according  to  the  size  of  the 
mass  to  be  removed.  If  the  incision  extends  beyond  the  umbilicus, 
most  operators  avoid  this  place,  as  being  thinner  and  less  favorable 
for  healing,  and  go  to  the  left  of  it ;  but  some  of  the  best  ovariotomists 
cut  right  through  it. 

2.  Removal  of  Cyst — When  the  peritoneal  cavity  is  opened,  the 
cyst  appears  in  the  wound  as  a  pearl-gray  glistening  body.  In  order 
to  reduce  its  size  the  patient  is  turned  on  the  side  facing  the  operator. 
Emmet's  trocar  (Fig.  320)  is  pushed  into  it  near  the  upper  end  of  the 
incision,  and  the  fluid  directed  down  into  a  tub  standing  under  the 
table.  Many  operators  prefer  to  let  the  patient  stay  on  her  back  and 
to  use  a  trocar  with  a  rubber  tube  attached,  leading  the  fluid  down 
into  the  vessel  destined  to  receive  it.  Howard  Kelly  has  devised  one 
of  glass,  which  is  cheap  and  easily  rendered  aseptic  by  boiling  with 
soda  (p.  199).1  As  soon  as  the  cyst  begins  to  collapse,  it  is  seized 
with  a  Nelaton  forceps  (Fig.  321)  and  pulled  out.  If  there  is 
much  fluid,  the  operation  is  considerably  expedited  by  withdrawing 
the  trocar  and  enlarging  the  opening  with  scissors.  After  a  little 
while  room  will  be  gained  for  the  application  of  a  second  Nelaton 

1  Kelly,  Amer.  Jour.  Obst.,  April,  1893,  vol.  xxvii.  p.  581. 


612 


DISEASES  OF  WOMEN. 


forceps,  and  sometimes   even  one  or   two  volsellae   may  answer  a 

FIG.  320. 


FIG.  321. 


Emmet's  Ovariotomy  Trocar. 

good  purpose  in  pulling  out  the  tumor.  If  there  are  several  large 
compartments,  they  are  opened  one  after  the  other  with  trocar,  scis- 
sors, or  fingers,  from  that  first  entered. 

During  the  removal  of  the  cyst  the  assistant 
compresses  the  abdomen,  and  is  particularly 
careful  to  prevent  the  protrusion  of  the  intes- 
tine. He  should  also,  during  the  following 
steps  of  the  operation,  always  keep  the  abdo- 
men closed  as  much  as  possible  by  approx- 
imating the  edges,  and  covering  the  incision 
with  a  sponge  or  a  gauze  pad. 

If  the  mass  of  the  cyst  left  after  evacuation  is 
still  heavy  or  bulky,  it  is  best  to  get  rid  of  it 
by  seizing  the  pedicle  in  a  temporary  ligature 
of  rubber  tubing  or  strong  silk,  or  with  Spen- 
cer Wells's  pedicle-forceps  (Fig.  322),  or  a 
cautery-clamp  (Fig.  323),  and  cutting  it  off  at 
a  distance  of  about  two  inches  above  the  com- 
pression. If,  on  the  other  hand,  the  cyst  is 
collapsed  and  light,  the  pedicle  is  simply  seized 
with  the  fingers.  As  described  under  salpingo- 
oophorectomy  (p.  536),  a  blunt  handled  needle 
is  used  to  carry  the  pedicle  ligature  through, 
and  the  Staffordshire  knot  (p.  536)  may  be 
Neiaton-s  cyst-forTeps?^,  u«ed ;  but  in  ovariotomy  it  is  more  convenient 
circular  jaws  with  holes  to  cut  the  pedicle-silk  in  two  halves,  cross 

and  pegs ;  B,  catch.  ,.-r         ,,,/,  ,   -\       .  i          /• 

them,  and  tie  each  half  separately,  thus  form- 
ing two  links  of  a  chain  perforating  and  surrounding  the  pedicle. 


DISEASES  OF  THE  OVARIES. 


613 


As  the  stump  of  the  Fallopian  tube  might  suppurate,  it  ought  to 
be  tied  as  close  up  to  the  uterus  as  convenient.     When  the  pedicle 


FIG.  322. 


Spencer  Wells's  Pedicle-forceps. 


has  been  tied,  it  is  cut  three-quarters  of  an  inch  above  the  ligature, 
and  treated  just  as  the  stump  in  salpingo-oophorectomy.  Finally,  it 
is  dropped,  the  intestine  kept  back,  and  the  omentum  spread  over  it. 


FIG.  323. 


Smith's  Cautery-Clamp. 

Some  draw  the  peritoneum  together  over  the  stump  and  close  it 
with  a  continuous  suture  of  catgut,  expecting  thereby  to  ward  off 
infection  and  adhesions  to  the  intestine ;  but  the  first  may  just  as  well 
take  place  through  the  peritoneal  covering,  and,  since  the  peritoneal 
endothelium  must  be  handled  in  stitching,  it  is  just  as  liable,  or  per- 
haps more  liable,  to  form  adhesions  than  the  raw  surface  dusted  with 
a  powder  like  iodoform  or  aristol. 

Others  sear  the  stump  over  the  ligature,  which  is  a  good  means  of 
preventing  absorption  and  adhesion,  but  which  shortens  the  stump 
and  invites  the  risk  of  burning  the  ligature,  unless  a  cautery-clamp 
is  used. 

On  the  other  hand,  it  is  a  double  assurance  against  hemorrhage  to 
seize  large  arteries  in  the  stump  and  tie  them  separately. 


614  DISEASES  OF  WOMEN. 

The  distal  end  of  the  stump  does  not  slough,  because  new  capil- 
laries are  speedily  formed  around  the  ligature,  which  carry  nourish- 
ment enough  to  the  part  beyond. 

The  silk  becomes  encapsulated,  and  is  slowly  absorbed ;  but  it  has 
been  found  as  late  as  two  years  after  it  had  been  put  in.  If  aseptic, 
it  is  entirely  innocuous. 

After  having  dropped  the  pedicle,  the  second  ovary  should  be  brought 
into  view  and  examined.  In  a  young  woman  it  ought  to  be  saved  if 
possible.  If  it  is  healthy,  nothing  is  done  to  it.  If  it  only  shows  a 
few  small  serous  cysts,  they  should  be  pricked  open.  A  larger  cyst 
may  be  cut  out  and  the  edges  united  with  a  continuous  catgut  suture. 
In  women  who  have  passed  the  climacteric  or  are  near  that  period  it 
is  safer  to  remove  the  second  set  of  appendages,  so  as  to  prevent  the 
formation  of  a  cyst  on  this  side.  The  same  rule  applies,  if  the  cyst 
is  cancerous,  as  experience  has  shown  that  in  such  cases  the  second 
ovary  is  predisposed  to  become  affected  in  the  same  way.  It  should 
also  be  removed,  if  the  uterus  is  the  seat  of  a  fibroid  (p.  483)  or 
if  for  any  other  reason  it  is  advisable  to  hasten  the  menopause. 

If  no  blood  or  other  fluid  has  escaped  into  the  peritoneal  cavity, 
no  attempt  should  be  made  to  clean  it,  but  the  wound  should  simply 
be  closed  when  the  rest  of  the  operation  is  finished. 

A  separate  nurse  should  have  care  of  sponges  and  gauze  pads,  and 
before  the  operator  proceeds  to  the  closure  of  the  wound  the  sponges, 
pads,  and  artery-forceps  should  be  counted,  as  it  has  happened  that 
such  objects  have  been  left  in  the  abdominal  cavity,  from  which  place 
they  often  have  been  removed  after  a  long  time,  and  after  much  injury 
had  been  caused. 

3.  Closure  of  the  Abdominal  Incision. — In  closing  the  wound  after 
laparotomies  great  care  should  be  taken  to  unite  the  different  layers, 
and  especially  the  fascial  and  aponeurotic  structures,  as  otherwise  a 
ventral  hernia  is  very  apt  to  form.  The  best  practice  is  first  to  close 
the  peritoneum  with  a  continuous  suture  of  thin  catgut,  put  in  either 
as  in  simple  sewing  or  as  for  buttonholes,  by  passing  the  needle 
through  each  loop  of  the  thread — the  so-called  glover's  suture.  The 
second  row  of  sutures  should  unite  the  aponeurotic  and  muscular  struc- 
tures. This  may  be  done  with  interrupted  sutures  or  a  running  suture 
of  strong  catgut.  A  particularly  solid,  but  a  little  more  tedious,  way 
is  to  use  the  cobbler's  stitch,  inserting  a  stitch  for  every  quarter  of  an 
inch  with  a  curved  handled  needle,  which  is  unthreaded  and  threaded 
again  with  the  other  end  of  the  thread  for  every  stitch,  so  that  the  two 
ends  pass  through  the  same  hole  (Fig.  327),  the  loops  lying  on  both 
sides  and  crossing  under,  not  above,  the  edges.  Catgut  or  kangaroo 
tendon  should  be  used.1  The  suture  should  be  tightened  for  every 

1  Henry  O.  Marcy,  Trans.  Amer.  Assoc.  Obstetricians  and  Gynecologists,  1889,  re- 
print, p.  23. 


DISEASES  OF  THE  OVARIES.  615 

two  or  three  stitches  sufficiently  to  cause  apposition  of  the  lateral  sur- 
faces, but  no  constriction.  Finally,  the  skin  and  subcutaneous  adipose 
tissue  are  united  by  deep  and  superficial  silk  sutures,  or  preferably  by 
a  subcuticular,  absorbable  running  suture,  inserted  parallel  to  the 
edges  of  the  wound  and  crossing  from  side  to  side,  at  right  angles, 
under  the  surface  (Fig.  272,  p.  493).  Before  closing  the  two  upper 
rows  of  sutures  the  wound  should  be  irrigated  with  some  antiseptic 
fluid  (p.  205). 

4.  Dressing. — When  all  the  sutures  have  been  tied  and  cut  off,  the 
abdomen  is  washed  with  a  solution  of  corrosive  sublimate,  the  wound 
dusted  with  iodoform,  a  compress  of  iodoform  gauze  laid  over  it,  and 
a  piece  of  gutta-percha  tissue,  an  inch  wider  than  the  compress  in  all 
directions,  placed  outside  of  it.     Next,  the  whole  anterior  surface  of 
the  abdomen  is  covered  with  a  thick  layer  of  sterilized  dry  absorbent 
cotton ;  this  is  held  in  place  by  two-inch-wide  straps  of  rubber  ad- 
hesive plaster ;  and,  finally,  a  flannel  binder  or  a  many-tailed  muslin 
bandage  is  put  around  the  whole  abdomen  and  pinned  in  front  with 
safety-pins. 

5.  After-treatment. — After  the  operation  the  patient  is  placed  in 
her   bed,  and   surrounded  by  half  a  dozen  bottles  filled  with   hot 
water.     If  there  is  no  shock,  she  is  allowed  to  sleep  till  she  awakes 
spontaneously.     If  she  vomits,  the  measures  recommended  on  p.  241 
are  taken.     The  urine  should  be  drawn  with  a  catheter  three  or  four 
times  a  day,  if  she  is  unable  to  pass  it  herself.     Opiates  should  be 
avoided  as  much  as  possible  on  account  of  the  danger  of  their  para- 
lyzing the  intestine.     Pain  may  often  be  considerably  relieved  by 
applying  an  ice-bag  to  the  abdomen ;  but  great  pain  is  weakening  and 
calls,  in  my  opinion,  for  a  hypodermic  injection  of  one-eighth  of  a 
grain  of  morphine. 

If  there  is  no  special  indication  for  doing  it  earlier,  the  bowels 
should  be  moved  by  a  gentle  aperient  on  the  third  day.  I  prefer  for 
this  purpose  a  heaping  teaspoonful  of  sulphate  of  sodium,  to  be  repeated 
every  four  hours  if  needed.  This  salt  tastes  much  better  than  sul- 
phate of  magnesium  and  does  not  gripe.  To  allow  the  bowels  to  be 
at  rest  too  long  is  dangerous,  because  it  may  give  rise  to  occlusion  of 
the  intestine  by  adhesions.  Before  the  bowels  are  moved  much  relief 
from  flatulence  is  afforded  by  introducing  a  soft-rubber  rectal  tube. 

During  the  first  day  no  food  is  given.  Thirst  is  relieved  by  very 
small  quantities  of  hot  or  ice-cold  water  or  an  enema  of  a  pint  of 
tepid  water.  The  following  days  the  patient  may  have  tea,  milk, 
thin  oatmeal  gruel,  and  beef-tea,  in  small,  frequently  repeated  portions 
(not  over  two  ounces  at  a  time).  After  the  first  week  she  may  have 
common  food. 

If  everything  goes  well,  the  dressing  is  not  touched  for  a  week. 
Then  the  sutures  are  removed  as  described  on  p.  220.  The  abdomen 


616  DISEASES  OF  WOMEN. 

is  washed  with  a  solution  of  corrosive  sublimate,  the  sutures  are 
replaced  by  strips  of  rubber  plaster,  half  an  inch  wide  and  cut  out  in 
the  middle  so  as  to  leave  free  exit  for  any  discharge  from  the  edges 
of  the  wound.  Then  a  similar  dressing  is  applied  as  at  the  time  of 
the  operation.  In  this  way  the  wound  is  dressed  once  a  week,  and 
the  patient  should  stay  in  bed  for  three  weeks. 

As  the  broad  straps  of  plaster  adhere  to  the  skin,  and  their  removal 
causes  some  pain,  it  is  better  to  cut  them  just  outside  of  the  cotton, 
leaving  the  ends,  and  fastening  the  new  straps  to  them,  until  finally, 
after  three  weeks,  all  is  removed.  Another  way  is  to  sew  pieces  of 
tape  to  straps  of  adhesive  plaster.  The  latter  are  fastened  to  the  side 
and  part  of  the  back  of  the  patient,  and  remain  undisturbed,  while 
the  tapes  cross  the  dressing  and  can  be  tied  or  untied  as  needed.  After 
removal  of  the  plaster  the  abdomen  is  cleaned  with  chloroform,  which 
dissolves  rubber  plaster,  and,  after  having  been  up  a  few  days  the 
patient  may  be  dismissed.  She  should,  however,  wear  an  abdominal 
belt  for  at  least  three  months. 

Difficulties  met  with  during  the  Operation. — If  an  ovarian  cyst  does 
not  contain  much  solid  matter,  has  no  adhesions,  and  has  a  long  and 
strong  pedicle,  ovariotomy  is  one  of  the  easiest  operations.  But  numer- 
ous and  manifold  are  the  difficulties  which  may  arise,  which  often 
cannot  be  foreseen,  and  for  which  the  operator  must  be  prepared. 

Bladder  in  Front  of  Tumor. — Just  as  we  have  seen  that  the  blad- 
der may  be  spread  over  the  front  of  a  uterine  fibroid  (p.  494),  so  this 
may  be  the  case  with  an  ovarian  cyst. 

Pei'sistent  Uraehus. — See  p.  495. 

Peritoneum  taken  for  Cyst-wall. — In  consequence  of  the  irritation 
caused  by  the  tumor  the  peritoneum  is  often  much  thickened,  and, 
taking  it  for  the  adherent  cyst-wall,  the  operator  has  sometimes  peeled 
it  off  from  the  abdominal  wall.  If  this  is  only  done  over  a  small  space, 
it  is  immaterial ;  but  if  a  large  surface  has  been  denuded,  the  peri- 
toneum, in  order  not  to  lack  nourishment,  and  to  prevent  suppura- 
tion, must  be  stitched  to  the  abdominal  wall  either  by  a  continuous 
catgut  suture  or  by  the  so-called  mattress-suture — i.  e.  interrupted 
sutures  going  through  the  whole  thickness  of  the  abdominal  wall — 
and  tied  over  a  quill  or  a  small  roll  of  adhesive  plaster. 

If  the  operator  is  in  doubt  whether  he  has  to  do  with  the  perito- 
neum or  the  adherent  cyst-wall,  it  is  better  to  continue  cutting  cau- 
tiously, even  at  the  risk  of  extending  the  incision  into  the  cyst. 

Adhesions  may  cause  great  trouble  or  even  render  the  extirpation 
impossible.  .  .. 

Adhesions  to  the  abdominal  wall  may  often  be  easily  severed  by 
pushing  a  male  urethral  steel  sound  between  the  abdominal  wall  and 
the  cyst  before  tapping.  If  there  is  much  resistance,  the  flat  hand  is 
introduced,  and  the  ulnar  edge  of  it  used  in  the  way  a  paper-cutter 


DISEASES  OF  THE  OVARIES.  617 

separates  the  leaves  of  a  book.  On  account  of  bleeding  it  is,  how- 
ever, not  safe  to  go  too  far  out,  and  more  resistant  adhesions  should 
be  left  till  the  cyst  has  been  emptied. 

If  the  adhesion  is  found  in  the  line  of  incision,  this  should  be 
extended  upward  above  the  adhesion,  until  a  point  is  reached  where  the 
abdominal  cavity  is  opened,  and  then  the  adhesions  should  be  attacked 
from  this  point.  If  this  cannot  be  done,  the  operator  should  cut  into 
the  sac  and  invert  it. 

Long  and  resistant  adhesions  are  cut  between  two  ligatures.  If 
they  are  too  short  for  that,  they  should  simply  be  cut  and  the  bleed- 
ing points  caught  with  pressure-forceps. 

Adhesions  to  the  intestine  are  very  serious.  If  an  adhesion  is  string- 
shaped,  it  may  be  torn  or  tied  between  two  ligatures.  If  it  is  broad, 
it  may  be  severed  by  pulling  on  the  sac  or  pushing  this  away  from 
the  intestine  by  means  of  a  sponge  on  sponge-holder.  If  it  does  not 
yield  readily,  a  piece  of  the  outer  layer  of  the  sac  is  cut  out,  and  left 
on  the  intestine  (p.  495).  If  the  adhesion  is  very  extensive,  it  is  bet- 
ter not  to  try  to  separate  it  at  all,  but  either  to  desist  altogether  from 
the  operation  or  be  satisfied  with  an  incomplete  operation  by  marsu- 
pialization,  as  will  presently  be  described. 

If  the  intestine  has  been  injured,  it  must  be  attended  to,  as  even 
the  smallest  puncture  may  allow  the  contents  to  enter  the  peritoneal 
cavity,  and  as  any  place  deprived  of  its  peritoneal  coat  is  apt  to 
rupture. 

A  mere  puncture  may  be  seized  with  forceps  and  surrounded  by  a 
ligature.  The  edges  of  a  longer  tear  must  be  brought  together :  if  it  is 
only  peritoneal,  they  may  be  united  with  a  continuous  suture;  but 
if  the  whole  wall  is  torn  through,  the  edges  should  be  united  by 
a  Czerny-Lembert  suture ;  that  is,  a  double  row,  the  inner  comprising 
the  muscular  layer  and  the  peritoneum,  but  not  the  mucous  mem- 
brane, the  outer  the  peritoneum  alone  a  quarter  of  an  inch  outside  of 
the  first.  A  fine  cambric  needle,  threaded  with  the  finest  iron-dyed 
black  silk,  is  used  for  this  delicate  work.  The  inner  suture  may  be 
interrupted  or  continuous ;  the  outer  is  always  continuous. 

If  the  intestine  has  suffered  much,  it  may  become  necessary  to 
excise  a  portion  of  it. 

Small  bleeding  surfaces  on  the  intestine  may  be  seared  by  holding- 
a  Paquelin  cautery  at  a  short  distance  from  them,  or  they  may  be 
touched  with  Monsel's  solution.  The  injured  part  should  be  kept 
near  the  incision,  so  as  to  favor  the  formation  of  a  fecal  fistula  in  case 
healing  fails  to  take  place.  Serious  injury  to  the  intestine  is  commonly 
fatal. 

Special  attention  should  be  paid  to  the  appendix  vermiformis.  If 
it  is  adherent  to  the  cyst,  and  not  easily  detached,  it  should  be  cut  off 
between  two  ligatures,  and  the  surface  remaining  in  the  body  thor- 


618  DISEASES  OF  WOMEN. 

oughly  disinfected,  or  the  stump  of  the  appendix  may  be  inverted  and 
the  peritoneum  united  with  a  running  suture. 

Adhesions  to  the  mesentery  are  vascular.  If  possible,  they  should, 
therefore,  be  tied  before  cutting.  If  that  is  not  feasible,  they  must  be 
cut,  and  a  suture  passed  under  the  bleeding  part.  As  much  as  possi- 
ble blunt  instruments,  such  as  a  pair  of  closed  blunt  scissors  or  the 
finger-nails,  should  be  used.  If  a  large  surface  has  been  denuded,  the 
edges  should  be  united  with  a  running  suture. 

Adhesions  to  the  omentum  are  common  and  bleed  easily.  They 
are  best  separated  with  a  sponge  squeezed  dry.  If  they  are  exten- 
sive, a  part  of  the  omentum  must  be  cut  off,  for  which  purpose  it 
must  be  ligated  in  sections.  A  larger  mass,  however,  can  safely  be 
tied  by  using  the  elastic  ligature  (p.  496).  Large  veins  may  extend 
all  alone  without  being  accompanied  by  other  tissue  from  the  omen- 
tum to  the  abdominal  wall  or  down  into  the  pelvis.  They  are  easily 
torn,  and  must  be  severed  between  two  ligatures.  No  rent  should 
be  left  in  the  omentum,  as  the  intestine  may  be  caught  in  it  and 
become  strangulated.  Its  edges  should  be  united  with  continuous 
catgut  sutures  or  the  whole  cut  off. 

Adhesions  to  the  liver  and  the  spleen  may  cause  severe  hemorrhage. 
If  they  are  not  easily  separated,  it  is  better  to  leave  part  of  the  cyst- 
wall  on  the  viscus.  Bleeding  from  these  organs  may  sometimes  be 
stopped  with  Paquelin's  cautery  or  Monsel's  solution,  and,  best  of  all, 
with  a  current  of  steam  directed  for  half  a  minute  against  the  bleed- 
ing surface.1 

The  operator  should  be  careful  not  to  tear  the  gall-bladder.  If  the 
accident  happens,  the  tear  must  be  comprised  in  the  sutures  closing 
the  abdominal  incision,  temporarily  establishing  a  biliary  fistula.  If 
this  organ  is  badly  torn,  it  is  necessary  to  remove  it  entirely. 

Adhesions  to  the  pelvis  are  the  worst  of  all,  as  they  are  broad, 
deep-seated,  and  may  implicate  the  ureter  or  large  vessels.  If  the 
tumor  is  small,  it  is  best  to  sever  them  before  emptying  it.  It  may 
be  necessary  to  do  so  guided  by  the  touch  alone,  although  a  great  help 
has  been  secured  just  for  such  cases  in  Trendelenburg's  position  (p. 
138).  It  may  be  better  to  leave  the  outer  layer  of  the  cyst  where  it 
is  adherent  or  to  cut  off  the  free  part  of  the  cyst  and  stitch  the 
remainder  to  the  abdominal  wound. 

The  ureter  may  have  to  be  dissected  out  in  order  to  free  it  from 
adhesions. 

If  the  ureter  is  injured  during  a  laparotomy,  the  injury  is  to  be 
remedied  in  one  of  the  following  ways :  if  the  wound  is  lateral,  the 
edges  should  be  united  by  suture  over  a  catheter  introduced  through 
the  wound,  partly  up  in  the  direction  of  the  kidney  and  partly  down 
into  the  bladder,  whence  it  is  pulled  out  with  a  forceps  through  the 

1  Snegireff,  Berliner  Klinik,  April,  1895. 


DISEASES  OF  THE  OVARIES.  619 

urethra;  or,  if  that  is  not  practicable,  an  iodoform  tampon,  made 
according  to  Mikulicz  (p.  181),  should  be  left  in  contact  with  the 
sutured  wound  in  order  to  save  the  peritoneal  cavity,  if  the  wound 
does  not  unite. 

If  the  ureter  is  torn  transversely,  but  the  ends  remain  in  contact 
with  each  other,  the  same  course  should  be  pursued. 

Sometimes  it  is  possible  to  introduce  the  upper  end  into  the  bladder 
and  stitch  it  there  bv  intra-peritoneal  or  extra-peritoneal  cystostomy 
(p.  375). 

If  no  conservative  method  is  available,  nephrectomy  should  be  per- 
formed at  once,  provided  the  patient  appears  able  to  stand  the  shock. 
If  she  is  too  weak,  a  provisional  urinary  fistula  should  be  established 
by  making  an  incision  in  the  lumbar  region,  suturing  the  upper  end 
of  the  ureter  to  it,  and  leaving  a  catheter  in  it.  The  other  end  is 
ligated  and  sutured  to  the  lower  end  of  the  abdominal  wound.  If  a 
fistula  forms  here,  another  catheter  is  introduced  and  left  in  it.  A 
third  is  introduced  through  the  urethra  into  the  bladder.  From  all 
three  catheters  rubber  tubes  go  into  vessels  containing  a  solution  of 
boric  acid.  When'the  patient  has  recovered,  the  kidney  is  extirpated.1 

If  the  uterus  has  been  wounded,  the  bleeding  may  usually  be 
stopped  by  passing  a  ligature  under  the  bleeding  point,  by  stitching 
some  loose  tag  of  peritoneum  to  it,  or  by  searing  it  with  the  thermo- 
cautery.  If,  however,  the  hemorrhage  cannot  be  checked  in  any 
other  way,  the  uterus  must  be  removed. 

The  cyst  may  be  so  adherent  everywhere  that  it  cannot  be  extirpated. 
In  making  the  first  incision  the  operator  enters  it,  and  the  sac  cannot 
be  inverted.  Then  there  is  nothing  to  be  done  except  to  empty  it, 
stitch  it  to  the  abdominal  incision,  wash  it  out,  and  pack  it  with  iodo- 
form gauze,  which  is  changed  every  four  or  five  days.  Under  this 
treatment  the  sac  shrinks  and  fills  with  granulations. 

If  an  irremovable  cyst  has  colloid  contents  contained  in  numerous 
small  compartments,  the  upper  and  lower  ends  of  the  incision  should 
be  seized  with  volsella3  and  held  up  against  the  abdominal  wall.  The 
compartments  should  be  broken  up  with  one  or  more  fingers  or  the 
whole  hand. 

Sometimes  adhesions  in  the  upper  part  may  be  overcome  by  seizing 
the  lowest  part  from  within  and  inverting  it.  In  other  cases  it 
suffices  to  let  an  assistant  introduce  his  hand  into  the  sac  and  put  it 
on  the  stretch,  while  the  operator  severs  it  from  its  surroundings. 

If  the  cyst  contains  much  solid  matter,  it  is  best  to  tie  the  pedicle 

and  extract  the  lower  end  first.     If  the  solid  matter  is  found  below, 

while  the  upper  part  forms  a  large  cyst,  the  trocar  should  be  pushed 

through  the  lower  solid  part  into  the  upper  cystic  part,  thus  giving 

1  Pozzi,  Centrcdbl.  f.  Gyndk.,  Feb.  4,  1893,  vol.  xvii.  p.  98. 


620  DISEASES  OF  WOMEN. 

an  outlet  to  the  fluid,  and  then  the  upper  part  should  be  pulled  out 
first.  If  it  becomes  necessary  to  pull  the  intestine  out  of  the  abdom- 
inal cavity  in  order  to  sever  adhesions  or  stanch  bleeding;,  it  should  be 
laid  on  the  upper  part  of  the  abdomen,  and  covered  with  cloths  wrung 
out  of  warm  salt  water  (p.  502).  Treudelenburg's  position  has,  how- 
ever, rendered  this  evisceration  superfluous  in  most  cases. 

Intraligamentous  Development. — Ovarian  tumors  that  develop  in 
the  broad  ligament  are  usually  papillary  (p.  580).  They  are 
smaller,  grow  more  slowly,  and  have  fewer  daughter-cysts.  Their 
papillomas  may  rupture  the  cyst- wall  and  lie  free  in  the  peritoneal 
cavity  or  grow  into  neighboring  organs.  They  are  more  malignant, 
and  are  very  apt  to  cause  metastatic  infection  of  the  peritoneum.  They 
are  difficult  to  remove,  and  special  care  must  be  taken  to  avoid  infec- 
tion. The  uterus  is  at  first  pushed  over  to  the  other  side  by  the  tumor, 
later  elevated  and  immovable.  When  the  lower  limit  of  the  broad  liga- 
ment is  reached,  the  tumor  may  develop  forward  or  backward.  If  it 
goes  forward,  it  strips  off  the  peritoneum  from  the  abdominal  wall,  and 
thus  it  is  reached  in  making  the  abdominal  incision  before  the  peritoneal 
cavity  is  opened.  Such  tumors  may  occasionally  be  removed  without 
entering  that  cavity  at  all,  but,  as  a  rule,  it  becomes  necessary  to  do 
so  at  a  later  stage  of  the  operation.  If  the  development  takes  place 
backward,  the  tumor  separates  the  layers  of  the  mesentery  and  comes 
to  lie  behind  the  large  and  small  intestine. 

The  intraligamentous  tumor  may  also  burst  through  its  peritoneal 
covering,  so  as  to  present  an  upper  intraperitoneal  and  a  lower  extra- 
peritoneal  part.  That  portion  which  is  free  from  the  peritoneum  has 
the  usual  pearl-gray  color  of  ovarian  cysts,  while  that  which  is  cov- 
ered with  peritoneum  is  pink.  In  exceptional  cases  the  tumor  is  even 
covered  with  a  thick  layer  of  unstriped  muscle-fibers,  which  gives  it 
the  appearance  of  a  uterine  tumor. 

The  ovarian  vessels  enter  the  tumor  at  ite  outer  border ;  the  uterine 
follow  the  Fallopian  tube  and  enter  on  the  middle  of  the  surface. 
The  intervening  part  of  the  broad  ligament  may  give  way,  so  that 
the  tumor  has  a  double  pedicle. 

Smaller  cysts  with  thin  walls  are  often  present,  and  the  uterus  usu- 
ally lies  in  the  angle  between  the  chief  cyst  and  the  smaller  ones. 

Rarely  the  whole  encapsulated  cyst  can  be  drawn  out  and  re- 
moved entire  by  forming  a  pedicle  of  the  broad  ligament.  If  the 
outer  and  lower  parts  of  the  ligament  are  free,  the  surgeon  may  put 
in  a  double  row  of  sutures,  beginning  at  the  infundibulopelvic  liga- 
ment, and  cut  the  tissue  that  lies  between  each  two  sutures,  whereby 
the  deeper  parts  become  more  accessible.  The  following  suture  must 
always  embrace  part  of  the  mass  comprised  in  the  preceding  one,  in 
order  to  avoid  hemorrhage.  (Compare  Vaginal  Hysterectomy,  p. 
487).  Proceeding  in  this  manner  we  get  under  the  cyst  and  diminish 


DISEASES  OF  THE  OVARIES.  621 

its  attachment,  until  finally  the  tube  and  the  rest  of  the  broad  liga- 
ment can  be  enclosed  in  one  ligature. 

If  the  cyst  extends  down  to  the  lower  edge  of  the  broad  ligament,  it 
can  only  be  removed  by  enucleation  (Miner's  method),1  which  consists 
in  stripping  the  cyst  of  its  peritoneal  covering,  and  leaving  this-  or 
part  of  it  as  an  empty  sac.  If  the  tumor  does  not  rise  much  above 
the  superior  strait  of  the  pelvis,  this  is  done  by  making  an  incision 
through  the  peritoneum  at  the  upper  end  of  the  tumor  and  pushing 
it  down  with  fingers  and  blunt  instruments.  If,  on  the  other  hand, 
the  cyst  is  large,  it  should  be  emptied  and  pulled  out  to  the  level  of 
the  abdominal  wall.  On  account  of  the  dangerous  character  of  the 
fluid  and  the  inner  wall,  the  opening  in  the  cyst  should  not  be  en- 
larged with  the  knife  nor  papillomata  broken  off,  but  the  hole  left 
by  the  trocar  should  be  closed  with  forceps.  Next,  a  small  incision 
is  made  on  the  anterior  surface  in  a  transverse  direction.  The  peeling 
is  begun  here,  and  it  is  gradually  extended  all  around  the  circum- 
ference. 

Before  doing  so  the  ovarian  vessels  should,  however,  be  tied  be- 
tween two  ligatures  and  cut ;  and  if  large  veins  are  found  in  the  invo- 
lucrum,  they  must  be  disposed  of  in  the  same  way.  Branches  of 
the  uterine  artery  which  are  severed  in  cutting  the  peritoneum  are 
also  tied.  When  the  ovarian  ligament  and  the  Fallopian  tube  come 
within  reach,  they  should  be  tied  and  cut;  and,  finally,  the  uterine 
attachment  is  tied  with  one  or  more  mass-ligatures.  They  include 
sometimes  a  part  of  the  uterus  itself,  and  it  may  even  become  neces- 
sary to  perform  supravaginal  hysterectomy  (p.  496). 

Often  a  large  part  of  the  uterus  is  left  without  peritoneal  covering, 
and  may  bleed ;  which  hemorrhage  may  be  checked  by  passing  a  con- 
tinuous catgut  suture  under  the  bleeding  surface  or  inserting  inter- 
rupted sutures  under  it  or  touching  it  with  the  thermocautery. 

It  often  happens  in  operations  involving  the  broad  ligament,  the 
cornu,  or  the  lateral  edge  of  the  womb  that  the  tissues  are  extensively 
torn  or  so  decomposed  as  to  break  down  under  the  fingers,  forceps,  or 
ligatures.  In  such  cases  hemorrhage  may  be  controlled  by  tying  one 
or  both  uterine  arteries  and  one  or  both  ovarian  arteries.  For  the 
purpose  of  tying  the  uterine  artery  the  uterus  should  be  drawn  toward 
the  opposite  side.  A  stout  curved  needle  armed  with  strong  silk  or 
catgut,  a  foot  long,  is  carried  a  quarter  to  half  an  inch  below  the  lower 
limit  of  the  tear,  just  entering  the  substance  of  the  uterus.  It  is  car- 
ried back  through  the  broad  ligament  about  half  an  inch  outside  of 
the  uterus  and  tied.  The  ovarian  artery  is  easily  secured  in  the  in- 

1  Julius  Francis  Miner  of  Buffalo,  N.  Y.,  performed  the  first  operation  of  this 
kind  in  1869,  and  in  the  following  year  published  the  method  (Atkinson  Biographi- 
cal Dictionary  of  Contemporary  American  Physicians  and  Surgeons,  Philadelphia,  1880, 
p.  45). 


622  DISEASES  OF  WOMEN. 

fundibulo-pelvic  ligament.  When  a  large  piece  of  the  broad  liga- 
ment has  been  removed,  the  raw  surface  may  be  disposed  of  by 
uniting  the  inner  edge  near  the  uterus  with  the  outer  near  the  pelvic 
wall  by  a  few  sutures,  thus  producing  an  artificial  latero-version.1 

The  development  into  the  mesentery  gives  rise  to  considerable  hem- 
orrhage, which  must  be  overcome  by  mass-ligatures.  Pieces  three  or 
four  inches  wide  may  be  ligated  without  causing  gangrene  of  the 
intestine. 

If  a  part  of  the  cyst  is  imbedded  in  the  pedicle,  its  inner  layer 
should  be  scraped  out  with  a  sharp  curette  or  seared  with  Paquelin's 
cautery. 

Sometimes,  as  a  result  of  inflammatory  processes,  the  peritoneum  is 
so  adherent  to  the  intraligamentous  ovarian  cyst  that  in  places  it 
cannot  be  stripped  off,  but  has  to  be  dissected  off  from  the  tumor 
with  a  knife,  or  the  separation  made  within  the  limits  of  the  tumor 
itself.  In  these  difficult  cases  the  peritoneal  covering  is  often  torn, 
and  severe  hemorrhage  may  take  place. 

If  papillomas  have  grown  from  the  ovarian  cyst  into  other  organs, 
these  parts  are  temporarily  left,  and  after  removal  of  the  tumor  they 
are,  as  far  as  possible,  scraped  out  with  nail  or  curette  or  cut  out 
with  the  knife,  to  which  treatment  the  uterus  lends  itself  more 
readily  than  other  organs. 

At  the  base  of  the  tumor  a  sharp  lookout  should  be  kept  for  the 
ureter,  which  runs  in  a  nearly  antero-posterior  direction,  and  is  rec- 
ognizable by  its  hardness.  Great  care  must  be  taken  not  to  tear  it, 
cut  it,  or  comprise  it  in  a  ligature. 

After  the  enucleation  a  large  raw  surface  is  left,  which  may  be 
treated  in  different  ways,  as  described  in  speaking  of  Fibroids  (p.  499). 

Pseudo-intraligamentous  Ovarian  Tumors.2 — There  is  a  kind  of 
ovarian  tumor  which  simulates  intraligamentous  tumors,  but  in  reality 
is  adherent  to  the  posterior  surface  of  the  broad  ligament,  which  it 
draws  up  in  front,  sometimes  high  up  in  the  abdominal  cavity.  The 
upper  end  and  the  posterior  surface  of  the  tumor  may  be  free  or 
covered  with  a  pseudo-membrane  of  peritonitic  origin,  which  is 
entirely  like  the  peritoneum.  The  bottom  adheres  to  Douglas's 
pouch.  These  pseudo-intraligamentous  tumors  can  hardly  be  diag- 
nosticated clinically  from  the  intraligamentous,  except  when  the  latter 
adhere  with  a  broad  surface  to  the  vagina  proper,  situated  laterally 
to  and  behind  the  uterus.  The  vagina  is  then  immovably  fastened 
to  the  lower  pole  of  the  tumor.  A  history  of  gonorrheal  or  puerperal 
peritonitis  makes  it  likely  that  the  tumor  is  pseudo-intraligamentous. 

Even  when  the  abdomen  is  opened,  it  may  be  quite  difficult  to 

1  H.   A.  Kelly,  Johns  Hopkintf  Hospital   Reports,  Gynecoloqy  1,  Baltimore,  Md., 
Sept.,  1890,  pp.  220-223. 

*  K.  Pawlik,  Ueber  Pseudo-interligameniose  Eierstocksgeschivulite,  Wien,  1891. 


DISEASES  OF  THE  O VARIES.  623 

recognize  the  true  condition,  and  still  it  is  of  great  importance,  since 
it  complicates  the  operation  very  much  if  the  operator  enters  the  space 
between  the- layers  of  the  broad  ligament. 

Sometimes  the  tube  may  be  separated  from  the  tumor,  and  the 
separation  continued  along  the  posterior  surface  of  the  broad  ligament, 
or  one  succeeds  in  getting  behind  and  under  the  tumor  and  loosen- 
ing it  from  the  peritoneum  in  Douglas's  pouch.  The  best  way  of 
removing  the  lower  end  of  the  tumor  is  to  pull  on  the  sac  after  free- 
ing it  from  adhesions  above,  and  tying  the  tube  with  a  double  ligature 
near  the  uterus,  and  severing  it  with  the  thermocautery. 

Incomplete  Operations. — Sometimes  it  is  impossible  to  remove  the 
tumor,  even  by  enucleation.  Then  three  methods  are  at  our  com- 
mand— viz. :  1 ,  marsupialization  ;  2,  to  leave  the  remainder  and 
close  the  abdomen ;  3,  drainage  through  the  vagina.  But  if  it  is 
evident  that  the  operation  cannot  be  finished,  it  is  better  not  to  ope- 
rate at  all.  The  conditions  which  make  it  impossible  to  perform  a 
complete  extirpation  are  general  adhesion  all  over,  subserous  devel- 
opment in  its  worst  forms,  and  cancer  which  has  spread  to  the  sur- 
roundings. 

Marsupialization  consists  in  stitching  the  edges  of  the  tumor  to 
those  of  the  abdominal  wall,  so  as  to  leave  a  pouch  which  has  been 
likened  to  that  in  which  marsupialian  animals  carry  their  young. 
This  method  is  particularly  indicated  in  monocystic  tumors.  If  it  is 
a  papillomatous  cyst,  all  vegetation  and,  so  far  as  possible,  the  whole 
mucous  layer  on  the  inside  of  the  cyst,  should  be  scraped  off.  Some- 
times the  whole  tumor  is  left  in  the  abdominal  cavity  ;  in  other  cases 
as  much  as  possible  is  removed,  and  the  rest  stitched  to  the  abdomen. 
If  the  opening  in  the  cyst  is  larger  than  that  of  the  abdomen,  the  cyst- 
wall  must  be  folded  so  as  to  adapt  itself  to  the  abdominal  incision.  The 
interior  of  the  cyst  is  packed  with  iodoform  gauze,  which  is  changed 
every  few  days.  After  a  week  when  adhesion  has  taken  place,  the  cyst 
may  be  injected  with  antiseptic  solutions.  The  sac  almost  invariably 
suppurates,  healing  may  take  many  months  or  even  a  year,  the  patient's 
strength  may  give  out,  a  fistula  may  remain,  or  a  relapse  may  occur. 
If  the  tumor  is  papillomatous,  proliferation  usually  continues  and 
puts  an  end  to  the  patient's  life  in  a  few  months.  If,  on  the  other 
hand,  everything  goes  favorably,  the  sac  fills  gradually  with  granula- 
tions, and  shrinks  until  the  wound  closes. 

If  the  tumor  is  polycystic,  it  is  better  to  leave  what  cannot  be  re- 
moved and  close  the  abdomen.1 

If  the  tumor  has  an  involucrum  so  full  of  large  blood-vessels  that 

the  operator  deems  it  impossible  to  remove  the  cyst,  he  may  puncture 

it  from  the  vagina  with  blunt  scissors,  dilate  the  opening  with  an 

expanding  dilator,  empty  the  cyst,  and  leave  a  drainage-tube  in  it. 

1  Olshausen  in  Billroth  and  Liicke's  Frcmenkrankheiten,  vol.  ii.  p.  591. 


624 


DISEASES  OF   WOMEN. 


But  this  vaginal  treatment,  like  the  abdominal,  may  give  rise  to  an 
interminable  secretion. 

It  has  been  suggested x  to  cut  off  the  blood-supply  of  the  tumor 
by  tying  the  ovarian  artery  in  the  infundibulopelvic  ligament,  and 
the  uterine  by  passing  a  ligature  round  it  with  a  curved  needle  from 
the  vagina  and  again  at  the  corner  of  the  uterus.  If  possible,  the 
cyst  should  then  be  stitched  to  the  wall,  opened,  and  drained.  If  the 
cyst  is  papillomatous  or  suppurating,  it  is,  however,  not  desirable  to 
proceed  in  this  manner,  on  account  of  the  danger  of  infection  in 
passing  the  sutures.  In  such  cases,  and  if  it  is  not  possible  to  stitch 
the  cyst  to  the  wall,  the  abdomen  is  closed,  the  dressing  applied,  the 
patient's  feet  are  lifted  up,  and  the  tumor  tapped  from  the  vagina. 
This  is  done  by  thrusting  a  pair  of  pointed  scissors  into  the  cyst  and 
opening  them  widely  on  withdrawal,  or,  better,  by  using  a  half  sharp- 
pointed  expanding  instrument  like  a  dilator  (Fig.  324),  and  introduc- 


FIG.  324. 


Half  Sharp-pointed  Pelvic  Puncturing  Dilator. 


ing  a  strong  blunt  dilator  (Fig.  325),  into  the  opening  made  with  the 
first,  and  expanding  it.     This  will  give  us  a  free  opening,  by  which 


FIG.  325. 


Blunt  Expanding  Pelvic  Dilator. 


we  can  both  empty  the  sac  and  ensure  free  washing  and  drainage.  A 
rubber  tube  should  be  stitched  in  the  wound,  or,  better,  the  sac  packed 
with  iodoform  gauze.  Later  on,  from  day  to  day,  the  mass  may  be 
broken  down  with  a  dull  curette  and  the  sac  injected  with  diluted 
tincture  of  iodine  of  increasing  strength,  or  peroxide  of  hydrogen. 

1  B.  McE.  Emmet,  Amer.  Jour.  Obst.,  July,  1890,  vol.  xxiii.  p.  706. 


DISEASES  OF  THE  OVARIES. 


625 


The  Pedicle. — If  the  pedicle  is  thick  and  short,  there  is  danger  of 
the  outer  part  of  the  ligature  slipping.  This  may  be  obviated  by 
repassing  it  near  the  edge  before  tying  it,  or  by  first  making  a  notch 
by  passing  a  finer  silk  ligature  around  the  pedicle  one-third  of  an  inch 
from  the  edge,  and  tying  it  before  tying  the  thick  pedicle-ligature. 


FIG.  326. 


Wallich's  Chain-ligature:—!.  P,  pedicle;  ppp,  pressure-forceps;  aa,  loops;— 2, ligatures  cut. 
crossed,  and  tied  loosely. 

If  the  pedicle  is  so  short  that  the  ligature  encroaches  on  the 
uterus,  it  is  a  protection  against  hemorrhage  to  unite  the  edges  of  the 
peritoneal  covering  of  the  stump  with  sutures.  If  it  is  very  thick, 
it  is  necessary  to  tie  it  in  more  than  two  parts  by  means  of  a  chain- 
ligature.  A  long  thread  is  carried  with  a  handled  needle  through 

40 


626 


DISEASES  OF   WOMEN. 


part  of  it,  and  seized  with  a  pressure-forceps.  Next,  the  long  end  of 
the  same  thread  is  carried  through  in  one  or  more  other  places,  and 
the  loops  secured  in  the  same  way.  When  all  are  in  place,  the  loops 


FIG.  327. 


Cobbler's  Stitch  for  Ligation  of  Pedicle. 

are  cut,  one  after  the  other,  near  the  forceps,  and  the  halves  crossed 
and  tied,  so  that  finally  the  whole  mass  to  be  ligated  is  enclosed  in 
threads,  forming  together  a  chain  (Fig.  326).  The  pedicle  may  be 
cut  gradually,  leaving  at  least  half  an  inch  of  tissue  above  the  liga- 
ture, and  for  greater  safety  it  is  advisable  to  tie  arteries  visible  on  the 
cut  surface  with  silk  or  catgut. 

Marcy's  Method1  (Fig.  327). — A  handled  needle,  carrying  a  long 
tendon  or  catgut  thread,  is  inserted  through  the  part  of  the  pedicle 

1  Henry  O.  Marcy  reported  this  method  at  the  International  Congress  in  London, 
1881,  and  claims  to  he  the  inventor  of  the  shoemaker's  stitch:  "The  Surgical  Ad- 
vantages of  the  Buried  Animal  Suture,"  Jour.  Amer.  Med.  Assoc.,  July  21,  1888, 
reprint,  p.  6. 


DISEASES  OF  THE  OVARIES.  627 

farthest  away  from  the  operator  (1).  One  end,  A,  is  held  by  the  assist- 
ant;  the  other  end,  B,  is  pulled  out  from  the  stitch-canal  and  the  eye 
of  the  needle  (2),  the  needle  threaded  with  A  (3),  pulled  back  (4),  and 
then  pushed  with  A  through  another  part  of  the  pedicle.  Now  A  is 
pulled  out  from  the  eye,  B  inserted  (5),  and  the  needle  pulled  back 
with  B.  Finally,  the  two  ends  are  tied  with  a  surgical  knot  over  the 
last  part  of  the  pedicle  (6).  This  does  not  tear  the  tissue,  and  com- 
presses the  whole  pedicle  tightly.  It  is  only  another  way  of  making 
a  cobbler's  stitch. 

In  dealing  with  thick  pedicles  it  is  also  useful  to  compress  them 
with  Spencer  Wells's  forceps,  so  as  to  form  a  notch  before  tying. 

If  a  hematoma  forms  under  the  ligature  of  the  pedicle,  another 
ligature  should  be  placed  nearer  the  uterus.  The  blood  between  the 
two  ligatures  is  left  to  be  absorbed. 

If  the  tube  appears  inflamed  or  if  the  stump  contains  parts  of  the 
cyst,  the  cut  surface  should  be  cauterized.  If  in  combination  with  a 
pedunculated  tumor  we  find  metastatic  masses  behind  the  peritoneum, 
the  latter  must  be  left  alone. 

If  the  pedicle  is  so  friable  that  the  ligature  cuts  through,  the  single 
vessels  must  be  secured  with  forceps  left  in  the  wound. 

After  the  removal  of  a  large  tumor  which  has  caused  great  dis- 
tention  of  the  abdominal  wall,  part  of  the  skin  and  peritoneum 
inside  of  the  recti  muscles  should  be  trimmed  off  before  closing 
the  wound. 

Toilet  of  the  Peritoneum. — If  adhesions  have  been  torn,  and  blood 
or  other  fluids,  such  as  pus,  cyst-contents,  etc.,  have  found  their  way 
into  the  peritoneal  cavity,  it  must  be  cleaned,  the  technical  term  for 
which  procedure  is  the  toilet  of  the  peritoneum.  Sometimes  it  is  enough 
to  introduce  a  few  sponges  or  pads  on  sponge-holders  into  Douglas's 
pouch.  If  the  bleeding  is  more  profuse  or  more  objectionable  fluids 
have  found  their  way  into  the  abdominal  cavity,  it  should  be  flushed 
with  hot  water  to  which  table-salt  has  been  added  in  the  proportion 
of  6  : 1000.  This  is  poured  into  it  from  a  pitcher  or  through  a  finger- 
thick  glass  tube.  This  saline  solution  comes  very  near  the  composi- 
tion of  serum,  and  attacks  the  epithelium  less  than  plain  water  or  an- 
tiseptic fluids.  If  there  is  still  some  oozing,  the  abdominal  packing 
with  iodoform  gauze  (p.  181)  may  be  used.  Only  if  there  seems  to 
be  a  decided  hemorrhage,  it  is  necessary  to  hunt  for  its  source  and  tie 
the  bleeding  vessel.  Experience  alone  can  guide  the  operator  in  this 
respect. 

Hemostasis. — For  arresting  hemorrhage  four  methods  are  avail- 
able— pressure,  ligature,  cauterization,  and  styptics. 

A  small  hemorrhage  may  be  arrested  by  simple  pressure  with  a 
finger  or  sponge.  A  liberal  use  of  pressure-forceps  saves  much  time 
by  avoiding  many  ligatures.  Bleeding  from  larger  surfaces  in  the 


628  DISEASES  OF  WOMEN. 

pelvis  may  be  arrested  by  packing  it  with  sponges,  pads,  or  cloths, 
which  should  be  left  in  sometimes  as  much  as  fifteen  minutes,  while 
counter-pressure  is  being  made  from  the  vagina,  and  removed  very 
cautiously,  so  as  not  to  tear  off  newly  formed  coagula. 

Sometimes  long  forceps  have  to  be  left  in  the  wound  till  the  next 
day,  but  this  should  be  avoided  as  much  as  possible.  It  is  better  to 
pack  the  peritoneal  cavity  with  iodoform  gauze  (p.  181).  After  the 
abdomen  has  been  closed,  pressure  may  yet  be  used  to  arrest  oozing  by 
means  of  a  tightly  'fitting  bandage  or  two  bricks  placed  outside  the 
dressing,  combined  with  packing  of  the  vagina  and  a  bag  filled  with 
ice-water  in  the  rectum  (p.  464). 

Bleeding  from  a  large  surface  on  the  anterior  abdominal  wall  may 
be  checked  by  folding  that  part  of  the  wall  and  excluding  it  from 
the  abdominal  cavity  by  passing  some  -quilled  sutures  at  the  base  of 
the  fold,  which  are  left  in  place  for  two  days  (Kimball's l  method). 

When  blood  may  be  expected  to  flow  from  both  ends  of  a  divided 
vessel,  it  is,  if  possible,  cut  between  two  ligatures.  If  this  is  not 
possible,  it  is  cut,  and  both  ends  are  seized  and  tied  or  compressed 
with  artery-forceps.  It  is  safest  to  tie  the  isolated  vessel  that  bleeds, 
but  often  this  cannot  be  done,  and  we  must  be  satisfied  with  a  mass- 
ligature  embracing  the  surrounding  tissue.  Bleeding  from  a  sur- 
face may  be  arrested  by  passing  a  continuous  suture  under  it  and 
drawing  it  together.  Sometimes  loose  tags  of  peritoneum  are  used  as 
a  patch.  Bleeding  from  the  anterior  abdominal  wall  may  sometimes 
be  arrested  by  tying  the  corresponding  epigastric  artery. 

Cauterization  has  become  quite  convenient  since  Paqueliu  invented 
his  thermocautery.  It  can  be  applied  to  bulky  organs,  such  as  the  ab- 
dominal wall,  the  uterus,  the  spleen,  and  the  liver ;  it  can  be  used  for 
cutting ;  and,  held  at  a  distance,  it  has  even  proved  successful  in  deal- 
ing with  hemorrhage  from  the  intestine. 

Tincture  of  iodine  or  Monsel's  solution  may  be  used  as  a  styptic  to 
smear  on  small  surfaces  of  delicate  organs,  such  as  the  intestine  or 
bladder,  but  their  use  ought  to  be  avoided  whenever  possible,  as  they 
form  coagula  which  may  become  a  source  of  inflammation  or  sepsis. 
Hot  water  is  an  excellent  hemostatic,  which  operates  by  causing  con- 
traction of  the  capillaries.  A  current  of  overheated  steam  led  through 
a  tube  ending  in  a  perforated  nozzle  like  the  rose  of  a  watering-pot  is 
said  to  be  effectual  in  arresting  hemorrhage  even  from  large  arteries 
(p.  618). 

In  order  to  find  the  bleeding  spot,  it  is  sometimes  necessary  to 
enlarge  the  incision  and  even  to  draw  out  the  intestine  (p.  535). 
The  search  may  be  facilitated  by  throwing  light  into  the  abdominal 
cavity  with  a  concave  mirror,  a  large  plane  mirror,  or,  still  better, 
with  a  portable  electric  lamp. 

1  Oilman  Kimball  of  Lowell,  Mass. 


DISEASES  OF  THE   OVARIES.  629 

Much  hemorrhage  may  be  avoided  by  tying  the  pedicle  as  soon  as 
possible,  before  beginning  to  separate  adhesions. 

Complications. — If  a  small  myoma  is  seen  in  the  uterus,  it  should 
be  let  alone,  but  its  presence  may  be  an  inducement  to  remove 
the  second  ovary  (p.  483).  A  large  myoma  may  be  in  the  way, 
and  have  to  be  removed  according  to  circumstances  (p.  483,  et  seq.). 

If  the  ovarian  cyst  is  accompanied  by  ascites,  nothing  should  be 
done  to  remove  the  latter  before  the  cyst  is  taken  away,  for  the  fluid 
serves  as  a  diluent  for  cyst-fluid  that  may  enter  the  peritoneal  cavity. 

If  the  patient  is  affected  with  an  umbilical  or  ventral  hernia,  its  sac 
should  be  dissected  out,  and  the  thinned  and  superfluous  tissues  cov- 
ering it  be  cut  away. 

Complication  with  pregnancy  has  been  considered  above  (p.  603). 
If  the  patient  is  not  seen  before  labor  has  set  in,  and  an  ovarian  tumor- 
obstructs  the  parturient  canal,  the  operator  should  try  to  push  it  up 
into  the  abdominal  cavity  in  the  genupectoral  position — a  treatment 
which  is,  however,  only  applicable  to  small  tumors.  A  large  tumor 
should  be  tapped  from  the  vagina  (p.  606).  If  it  does  not  collapse 
sufficiently,  an  incision  may  be  made  in  the  vagina,  and  the  tumor 
removed  or  diminished  in  this  way.  If  it  contains  much  solid  matter, 
craniotomy  or  Cesarean  section  may  be  preferable.  In  the  latter  case 
ovariotomy  should  be  added. 

Drainage. — We  have  seen  in  the  general  part  of  this  work  (p.  186) 
that  the  most  experienced  laparotomists  entertain  very  divergent 
views  as  to  the  use  of  drainage.  While  some  look  upon  it  as  a  fifth 
emunctory,  of  Avhich  they  are  very  willing  to  avail  themselves,  others 
are  loth  to  have  recourse  to  it.  In  a  general  way  it  may  be  stated 
that  it  is  indicated  when  pus  or  other  irritant  fluid  has  entered  the 
peritoneal  cavity  during  the  operation ;  when  sepsis  or  peritonitis  is 
present;  when  there  is  much  ascites,  especially  in  connection  with 
papillomata ;  when  there  are  many  or  large  raw  surfaces  left ;  when 
the  bladder  or  intestine  has  been  wounded  during  the  operation  or  is 
found  in  a  sloughy  condition ;  and  when  the  operator  is  in  doubt 
about  the  efficacy  of  his  hemostasis.  In  the  last  case,  if  a  tube  is 
used,  it  should  be  kept  pumped  out,  as  coagulation  then  takes  place 
more  readily  than  when  blood  accumulates  in  it. 

If  a  tube  is  used,  it  should  be  without  side  holes,  granulations  being 
apt  to  grow  into  them  ;  and  even  if  the  tube  has  no  lateral  openings,  it  is 
well  to  turn  it  on  its  axis  once  a  day  in  order  to  prevent  too  firm  adhe- 
sion. It  is  also  well  to  lift  the  tube  half  an  inch  and  let  it  drop  back 
by  its  own  weight,  so  as  to  avoid  too  much  pressure  and  the  formation 
of  a  fecal  fistula.1  But,  as  a  rule,  it  is  enough  to  leave  the  tube  for  one 
or  two  days  in  the  peritoneal  cavity  or  an  empty  pouch.  When  only 
a  teaspoonful  of  fluid  accumulates  in  several  hours,  the  tube  can  safely 
1  Wm.  Goodell,  Mann's  Amer.  Syst.  of  Gynecol.,  vol.  ii.  p.  819. 


630  DISEASES  OF  WOMEN. 

be  withdrawn.  If  it  is  used  in  incomplete  operations,  it  should  be 
left  in  as  long  as  there  is  secretion  of  pus.  In  the  latter  case  injection 
with  antiseptic  fluid  is  made  through  it,  whereas  in  completed  operations 
no  injections  should  be  used,  as  they  are  apt  to  tear  protective  adhesions. 
A  hole  is  cut  for  the  tube  in  the  dressing ;  a  piece  of  gutta-percha 
tissue  is  drawn  tight  up  to  the  flange  of  the  tube  and  folded  over 
some  loose  iodoform  gauze  outside  the  dressing,  which  allows  us  to 
change  the  gauze  and  empty  the  tube  without  disturbing  the  dressing. 
In  order  to  avoid  secondary  infection  of  the  sutures,  it  is  well  to  use 
silver  wire  for  the  two  that  are  in  direct  contact  with  the  tube.  One 
of  them  should  be  left  open  until  the  tube  is  removed. 

The  tube  has  to  a  great  extent  been  replaced  by  iodoform  gauze, 
which  has  the  advantage  of  being  soft  and  of  helping  to  check  hem- 
orrhage. It  may  be  left  in  place  from  three  days  to  a  week. 

The  objections  to  the  use  of  drainage  in  the  peritoneal  cavity  are 
that  it  irritates  the  peritoneum,  may  cause  uncontrollable  vomiting, 
interferes  with  free  movements  of  the  intestine,  predisposes  to  intes- 
tinal obstruction,  the  formation  of  fecal  fistula  and  ventral  hernia, 
and  maintains  a  danger  of  infection.1 

Some  prefer  drainage  through  the  vagina,  a  method  which  has 
already  been  referred  to  in  speaking  of  enucleation  of  fibroids  from 
the  broad  ligaments  (p.  499),  which  is  particularly  indicated  in  cases 
in  which  the  tumor  extends  far  down  into  Douglas's  pouch,  and  by 
which  ventral  hernia  is  avoided.  It  is  established  by  means  of  iodo- 
form gauze  or  a  soft-rubber  drainage-tube.  Two  fingers  are  passed  up 
through  the  disinfected  vagina  to  the  posterior  vault.  An  opening 
is  made  from  above  through  the  bottom  of  Douglas's  pouch  with 
scissors  or  trocar,  and  dilated  with  forceps  or  an  expanding  dilator, 
until  a  finger  can  easily  be  passed  through  it.  A  strip  of  iodoform 
gauze,  four  inches  wide,  is  passed  through  from  above  into  the  vagina, 
and  packed  in  or  around  the  part  from  which  one  wishes  to  drain. 
After  closure  of  the  abdominal  cavity  the  vagina  is  packed  with  iodo- 
form gauze.  If  there  is  a  rise  in  temperature,  the  vaginal  packing 
should  be  removed,  and  the  abdominal  gauze  pulled  out  a  few  inches, 
which  produces  free  drainage.  At  the  expiration  of  from  eight  to 
twelve  days  the  last  of  the  abdominal  gauze  should  be  withdrawn. 
If  there  yet  is  a  purulent  discharge,  a  soft-rubber  drainage-tube  with 
crossbar  should  be  introduced  instead.2  Such  tubes  cause,  however,  a 
good  deal  of  irritation,  make  the  vagina  very  tender,  and  may  pro- 
duce ulcers,  a  condition  which  is  successfully  combated  by  injecting 
stearate  of  zinc  with  a  powder-blower  into  the  vagina,  after  having 

1  A  strong  plea  in  its  favor  is  made  by  E.  W.  Gushing  of  Boston,  Mass.,  supported 
by  Lawson  Tait  and  Bantock,  in  Annals  of  Gynecology,  Nov.,  1890,  vol.  iv.  p.  69. 

1  H.  T.  Hanks,  "Counter-drainage  after  Cceliotomy,"  The  Post- Graduate,  No.  4,, 
1893. 


DISEASES  OF  THE  OVARIES.  631 

injected  a  saturated  solution  of  boric  acid  through  the  tubes  and  into 
the  vagina. 

Shock. — The  sudden  giving  out  of  vitality  called  shock  is  very 
dangerous,  and  calls  for  immediate  attention.  We  have  already 
spoken  of  this  condition  in  treating  of  the  operations  for  uterine 
fibroid  (p.  501).  Much  may  be  done  to  prevent  it,  not  only  by 
proper  attention  to  the  anesthesia,  but  by  preventing  hemorrhage, 
by  keeping  the  patient  warm,  by  avoiding  as  much  as  possible 
handling  the  intestine,1  and  by  abbreviating  the  duration  of  the 
operation  as  much  as  other  considerations  allow  us  to  do. 

If  it  threatens,  death  may  yet  be  averted  by  'the  hypodermic  injec- 
tion of  digitalis,  nitroglyceriu,  and  strychnine,  the  intramuscular  in- 
jection of  camphor  (p.  210),  the  rectal  injection  of  hot  water,  injection 
into  the  peritoneal  cavity  of  a  hot  saline  solution  (p.  502),  or  rapidly 
interrupted  compression  of  the  heart  (p.  207),  and  by  finishing  the 
operation  in  the  shortest  possible  time. 

Complications  during  After-treatment. 

Shock. — If  shock  is  present  after  the  patient  has  been  brought  to 
bed,  she  should  be  roused  (p.  223)  and  stimulated  as  just  described. 

Vomiting. — If  the  patient  vomits,  the  medicine  with  hydrocyanic 
acid  mentioned  on  p.  211  should  be  administered.  Deep  inspirations 
may  be  tried,  by  which  air  containing  remnants  of  the  anesthetic  is 
expelled  from  the  deeper  part  of  the  lungs.  If  vomiting  continues 
at  a  time  when  the  patient  should  take  food,  the  different  modifica- 
tions of  milk — peptonized  milk,  kumiss,  or  matzoon — can  often  be 
retained  when  everything  else  is  ejected.  If  the  patient  vomits 
everything  ingested,  she  must  be  fed  by  rectal  alimentation,  for 
which  milk,  eggs,  and  beef  extracts  are  particularly  useful.  As  a 
rule,  an  ounce  of  brandy  should  be  added.  The  whole  enema,  in 
order  to  be  retained,  should  not  be  more  than  four  ounces. 

If  vomiting  accompanies  intestinal  obstruction,  calomel  is  the  best 
remedy. 

Internal  Hemorrhage. — After  bloody  operations  the  patient  may  be 
very  weak  and  restless,  with  a  weak,  rapid,  and  irregular  pulse  ;  but 
if  there  is  no  bleeding,  this  condition  will  yield  to  the  free  use  of 
stimulants. 

Real  hemorrhage  comes  nearly  always  from  the  pedicle,  rarely  from 
large  raw  surfaces.  If  a  drainage-tube  has  been  left  in  the  abdomen, 
the  continuous  reproduction  of  pure  blood  furnishes  the  diagnosis. 
Otherwise  it  must  be  made  by  the  general  condition  of  the  patient — 
weakness  ;  restlessness  ;  weak,  rapid  pulse  ;  cold,  clammy  skin  ;  and 

1  Goltz  has  shown  that  a  continuation  "of  small,  insignificant  raps  on  the  belly  of  a 
frog  kills  it.  , 


632  DISEASES  OF  WOMEN. 

swelling  of  the  abdomen.  Then  only  two  sutures  should  be  removed, 
which  will  suffice  to  ascertain  the  presence  of  blood  in  the  abdominal 
cavity.  If  it  is  found,  the  whole  wound  must  be  reopened,  and  the 
source  of  the  hemorrhage — first  of  all,  the  pedicle — looked  for. 
When  found,  the  bleeding  is  arrested  by  means  of  ligatures,  and  the 
cavity  cleaned  and  closed  again.  If  the  patient  has  lost  much  blood, 
a  subcutaneous  injection  of  saline  solution  (p.  502)  may  prove  of 
great  value. 

Tympanites  without  inflammation  is  much  relieved  by  the  introduc- 
tion of  a  soft-rubber  rectal  tube  ;  by  enemas  with  turpentine  (gss  to 
Oj),  sulphate  of  qiu'nine  (gr.  v  every  four  hours),  or  mentha  viridis 
(3ij  to  aquse  Oj) ;  by  the  administration  of  tinct.  nucis  vomicae  or 
tinct.  capsici  (ITtv  every  hour),  or  large  doses  of  subnitrate  of  bismuth 
(gr.  xxx-xl) ;  by  standing  the  patient  on  her  head ;  by  nicking  the 
plaster  straps  crossing  the  abdomen,  drawing  up  her  knees,  using 
faradization,  or  puncturing  the  transverse  colon. 

Elevation  of  Temperature. — The  temperature  should  not  rise  above 
100°  Fahr.  As  soon  as  it  does,  the  cause  should  be  looked  for, 
which  may  be  constipation,  emotions,  suppuration  of  a  stitch-canal,  a 
mural  abscess,  peritonitis,  or  sepsis.  An  ice-bag  or  rubber  coil  with 
running  ice-water  should  be  applied  outside  of  the  dressing.  Anti- 
pyretic drugs  should  be  administered.  One  or  more  sutures  may  be 
removed  to  give  exit  to  pus. 

If  the  temperature  rises  more  than  two  degrees  above  the  normal 
average,  and  swelling  of  the  abdomen  announces  approaching  peri- 
tonitis, the  bowels  should  be  moved  at  once,  which  may  be  done  with 
sulphate  of  sodium,  a  teaspoonful  every  hour,  and  an  enema  with 
ox-gall  (p.  174)  given  in  the  mean  time. 

/Suppression  of  Urine. — If  the  secretion  of  urine  stops,  it  should 
be  promoted  by  giving  digitalis  and  acetate  of  potassium. 

If  a  ureter  has  been  tied  or  injured,  a  urinary  fistula  may  form 
in  the  vagina,  which  should  not  be  interfered  with  until  the  pa- 
tient has  recovered.  Hydronephrosis  has  developed,  and  been 
cured  by  extirpation  of  the  corresponding  kidney.  In  another  case 
a  cure  was  effected  by  pushing  a  trocar  through  the  urethra  and 
bladder  into  the  abnormal  reservoir,  and  leaving  the  canula  till  heal- 
ing had  taken  place.  Perhaps  it  might  suffice  to  remove  the  ligature 
from  the  uterine  artery  (p.  503).  If  not,  the  ureter  may  be  cut  above 
the  ligature  and  implanted  into  the  bladder  by  intra-  or  extra-perito- 
neal uretero-cystostomy  (p.  375). 

Intestinal  obstruction  is  marked  by  constipation,  vomiting,  and  tym- 
panites. It  is  often  due  to  adhesion  between  the  stump  of  the  pedicle 
and  the  intestine,  and  is  now-a-days,  as  a  rule,  avoided  by  moving  the 
bowels  early.  If  this  grave  complication  occurs,  large  ox-gall  enemas 
(p.  174)  should  be  given.  By  using  a  fountain  syringe  and  low  press- 


DISEASES  OF  THE  OVARIES.  633 

ure  (p.  175)  several  quarts  may  be  injected.  Calomel  is  the  best  ape- 
rient, because  it  is  least  likely  to  be  vomited.  Tinct.  belladonnas  or 
atropine  may  help  to  relax  the  bowel. 

A  very  efficacious  remedy  is  to  wash  out  the  stomach  with  five  or 
six  quarts  of  lukewarm  solution  of  table-salt,  which  produces  strong 
peristaltic  movements  of  the  intestine.  If  this  does  not  give  relief, 
a  second  lavage  is  made,  followed  by  the  introduction  of  nearly  two 
ounces  of  castor  oil  through  the  stomach-tube.1 

If  these  milder  means  fail,  the  abdomen  must  be  reopened  and  the 
obstruction  removed  manually. 

Septic  Peritonitis. — In  spite  of  all  antiseptic  precautions,  some  pa- 
tients develop  peritonits,  which  is  probably  always  of  septic  origin, 
and  may  lead  to  general  septicemia  and  death.  The  infection  cannot 
.always  be  blamed  on  the  operator,  as  it  would  seem  that  pathogenic 
microbes  can  find  their  way  through  the  wall  of  the  intestine  to  the 
peritoneal  cavity  (p.  502),  where  they  find  an  excellent  soil  in  blood 
and  serum.  Often  the  drainage-tube  has  been  the  door  through  which 
infection  has  entered. 

Peritonitis  develops,  as  a  rule,  within  four  days.  It  is  character- 
ized by  green  vomit,  tympanites,  tenderness  of  the  abdomen,  and 
a  frequent  pulse.  Often  there  is  no  rise  in  the  temperature,  which, 
on  the  contrary,  may  be  subnormal. 

The  bowels  should  be  moved  at  once,  five  grains  of  quinine  or 
salophen  given  every  four  hours,  brandy  administered  freely,  and  an 
ice-bag  or  ice-water  coil  applied  to  the  abdomen.  Finally,  the  wound 
may  be  reopened  and  the  peritoneal  cavity  washed  out  with  peroxide 
of  hydrogen,  but  the  chance  of  recovery  is  then  slim  indeed.  I  have 
seen  a  patient  who  evidently  was  dying  of  septicemia  saved  by  merely 
taking  out  a  couple  of  sutures  from  the  abdominal  incision,  which 
gave  exit  to  a  great  amount  of  gas.  Nothing  was  injected,  and  the 
abdomen  was  closed  again. 

If  peritonitis  supervenes  as  late  as  ten  to  fifteen  days  after  the 
operation,  it  is  probably  due  to  mortification  of  the  pedicle  or  other 
large  masses  that  have  been  ligated,  and  treatment  is  then  nearly 
powerless. 

A  mural  abscess  is  recognized  by  hardness  and  tenderness  of  the 
affected  part.  A  small  opening  should  be  made,  a  drainage-tube  in- 
serted, and  the  abscess-cavity  washed  out  daily  with  peroxide  of  hy- 
drogen. If  the  abscess  has  formed  around  a  suture,  this  should  be 
removed,  the  pus  pressed  out,  and  the  dressing  changed  daily. 

A  deep  abscess  may  be  made  out  by  bimanual  examination.  If  it 
lies  close  up  to  the  vagina,  it  should  be  opened  and  drained  from  that 
point.  If  not,  the  abdomen  must  be  reopened,  cleaned,  and  drained 
either  through  the  skin  or  through  the  vagina. 

1  Klotz,  Centralblatt  f.  Gyndk.,  1892,  vol.  xvi.,  No.  50,  p.  977. 


634  DISEASES  OF   WOMEN. 

Emphysema  of  the  abdominal  wall  is  rare,  but  is  of  importance,  in 
so  far  as  it  predisposes  to  the  formation  of  an  abscess. 

Spontaneous  reopening  of  the  wound  is  an  unfortunate  occurrence 
that  may  to  a  great  extent  be  prevented  by  keeping  the  bowels  open, 
by  not  removing  the  sutures  too  soon  (some  think  they  ought  even  to 
be  left  in  for  ten  days),  and  by  replacing  them  by  plaster  strips,  as 
recommended  above  (p.  616).  If  it  happens,  the  patient  should  be 
anesthetized,  and  new  sutures  put  in.  It  may  be  so  difficult  to 
replace  the  intestine  that  it  becomes  necessary  to  puncture  it  and 
let  the  gas  escape.  Before  replacing  it,  it  should  be  washed  with  the 
normal  solution  of  chloride  of  sodium. 

Sometimes  a  fistulous  tract  leads  into  the  abdominal  cavity,  and 
resists  healing  for  a  long  time.  Patients  affected  with  tuberculosis, 
syphilis,  or  cancer  are  predisposed  to  this  untoward  accident.  In 
most  cases  it  is  due  to  the  mechanical  irritation  caused  by  a  drainage- 
tube  or  suture-  and  ligature-material.  Sometimes  the  cause  is  sepsis. 
It  not  only  protracts  convalescence,  but  may  lead  to  the  formation  of 
a  fecal  or  urinary  fistula,  nephritis,  and  exhaustion.  Many  such 
fistula?  heal  by  nature's  sole  efforts  under  favorable  hygienic  circum- 
stances, and  the  use  of  nourishing  food.  Daily  irrigation  with  hot 
water  or  mild  antiseptic  fluids,  especially  the  peroxide  of  hydrogen, 
contributes,  however,  much  toward  a  favorable  result.  Sometimes 
much  time  can  be  saved  by  dilating  the  fistulous  canal  sufficiently 
to  introduce  a  fine  pair  of  forceps  and  pulling  out  a  ligature  from 
the  bottom.  Packing  with  iodoform  gauze  or  marine  lint  soaked  in 
balsam  of  Peru  is  also  often  useful.  Strong  fluids  and  severe  ma- 
nipulations must  be  avoided,  as  they  may  make  the  condition  worse 
by  wounding  the  intestine.1  In  protracted  cases  the  best  treatment 
is  to  make  an  incision  in  the  abdominal  wall  at  the  opening  of  the 
fistula,  and  dissect  out  the  whole  wall  of  the  same,  whether  it  becomes 
necessary  for  that  purpose  to  enter  the  peritoneal  cavity  or  not.  A 
rubber  drainage-tube  or  a  strip  of  iodoform  gauze  is  left  in  for  a  few 
days,  and  then  replaced  by  catgut  strands,  which  contribute  to  the 
healing. 

Fecal  fistula  is  a  rare  complication.  It  is  due  to  injury  of  the 
intestine  during  the  operation  or  to  pressure  from  a  drainage-tube. 
It  may  occur  as  late  as  two  or  three  weeks  after  the  operation. 

The  accident  may  be  prevented  by  enlarging  the  abdominal  incis- 
ion, if  there  are  many  adhesions,  and  using  Trendelenburg's  position, 
so  as  to  obtain  a  view  of  adhesions  that  implicate  the  intestine ;  by 
using  iodoform  gauze  as  a  drain  instead  of  hard  tubes ;  and  by  using 
silk,  not  catgut,  in  repairing  injury  to  the  intestine. 

To  operate  for  fecal  fistula  is  dangerous  and  unnecessary,  for,  as  a 

1  A  valuable  paper  on  this  subject  by  Andrew  F.  Currier  of  New  York  is  found 
in  Annals  of  Gyncecology,  July,  1892,  vol.  v.  No.  10,  p.  577. 


DISEASES  OF  THE  OVARIES.  635 

rule,  it  closes  spontaneously  within  a  year.  The  fistula  should  be 
tamponed  with  marine  lint  soaked  in  Peruvian  balsam,  or  gauze 
impregnated  with  iodoform,  aristol,  or  dermatol,  and  the  dressing 
renewed  daily.  When  the  opening  in  the  bowel  becomes  very  small, 
the  intestines  should  be  emptied  by  a  cathartic,  then  kept  at  rest 
for  a  week,  and  then  again  moved  by  enemas.  When  the  hole  in  the 
intestine  is  closed  the  same  dressing  should  be  kept  up  until  the  sinus 
heals  up  from  the  bottom.1 

Tetanus  is  also  a  rare  complication,  and  the  prognosis  is  very  bad. 
It  should  be  treated  with  chloroform,  chloral,  and  curare,  or  a  sub- 
cutaneous injection  of  a  specific  antitoxin. 

Phlebitis  occurs  sometimes.  The  affected  leg  should  be  raised  on 
pillows,  painted  with  tincture  of  iodine,  wrapped  in  cotton  batting 
and  slightly  compressed  with  a  roller-bandage. 

Great  care  should  be  taken  not  to  press  much  on  the  swollen  vein, 
as  a  clot  may  be  detached,  and  cause  sudden  death  by  embolism  of  the 
pulmonary  artery. 

Parotitis  is  a  rare  occurrence.  The  swelling  of  the  parotid  gland 
may  simply  be  due  to  the  mysterious  consensus  between  that  organ 
and  the  genital  gland,  also  frequently  observed  in  man.  It  is  then 
of  slight  importance,  and  soon  ends  in  resolution.  But  it  may  also 
be  part  of  a  septic  infection,  and  then  it  has  a  tendency  to  suppurate, 
and  is  a  serious  complication. 

Mental  Aberration. — In  rare  cases  ovariotomy  is  followed  by 
mania,  melancholia,  and  temporary  or  permanent  insanity.  This 
complication  is  most  apt  to  arise  in  patients  with  an  hereditary 
predisposition. 

If  both  ovaries  have  been  removed,  menstruation  stops,  as  a  rule, 
but  may  continue  for  a  few  months.  (Compare  pp.  119  and  539.) 

If  one  ovary  has  been  left  behind,  pregnancy  may  occur,  and  it,  as 
well  as  the  ensuing  childbirth,  offers  nothing  abnormal,  except  that 
the  cicatrice  is  subjected  to  such  a  strain  that  it  needs  protection  by 
means  of  an  abdominal  belt. 

If  both  ovaries  have  been  removed,  the  patient  is,  as  a  rule,  sterile. 
(In  regard  to  an  exception  to  the  rule  and  its  explanation,  see  p. 
549.) 

Prognosis. — The  technique  of  ovariotomy  has  been  brought  to  such 
a  degree  of  perfection  that  in  the  hands  of  the  most  skillful  operators 
the  mortality  has  been  reduced  to  5  per  cent.  Circumstances  that 
make  the  prognosis  good  are  a  good  constitution,  a  hopeful  disposi- 
tion, absence  of  disease  in  other  organs,  a  unilocular  or  paucilocular 
cyst,  a  good  pedicle,  and  absence  or  easy  separability  of  adhesions. 

Death  is  commonly  due  to  shock,  hemorrhage,  peritonitis,  or  septi- 

1  An  interesting  paper  on  fecal  fistula?  after  laparotomy  by  A.  Palmer  Dudley 
is  found  in  Amer.  Jour.  Obst.,  Feb.,  1892,  vol.  xxv.  pp.  145-163. 


636  DISEASES  OF  WOMEN. 

cemia,  to  which  are  added  the  rarer  causes,  such  as  exhaustive  sup- 
puration, uremia,  tetanus,  or  embolism.1 

B.  Solid  Ovarian  Tumors. 

Solid  ovarian  tumors  are  much  rarer  than  cystic  tumors  of  the 
ovary  and  solid  uterine  tumors.  They  may  be  fibroids,  papillomas, 
sarcomas,  endotheliomas,  carcinomas,  or  tuberculous. 

I.  Fibroma. 

Pathological  Anatomy. — Fibroids  of  the  ovary  are  usually  small, 
not  larger  than  a  hen's  egg  or  an  orange,  but  may  reach  the  size  of  an 
adult's  head,  or  even  become  enormous,  weighing  over  sixty  pounds. 
They  are  smooth,  globular,  and  nodular,  like  uterine  fibroids ;  but, 
unlike  them,  if  they  do  not  comprise  the  whole  ovary,  they  are  inti- 
mately connected  with  the  surrounding  tissue,  and  cannot  be  shelled 
out.  They  may  be  hard  or  so  soft  as  to  become  fluctuating.  They 
are  most  frequently  found  on  one  side  only,  but  may  be  bilateral. 
They  may  be  diffuse — i.  e.  comprise  the  whole  ovary — or  circumscribed, 
occupying  only  a  part  of  it,  and  then  generally  the  outer  end,  while 
the  remainder  is  in  a  condition  of  chronic  oophoritis  (p.  559). 

The  cut  surface  shows  translucent  gray  or  yellowish  places  alter- 
nating with  opaque  white  ones.  The  follicles  have  disappeared.  The 
tissue  is  composed  of  fine  fibrillar  connective  tissue,  peculiarly  rich 
in  long  spindle-cells.  Sometimes  it  contains  smooth  muscle-fibers, 
in  other  cases  none. 

As  a  rule,  the  mesoariurn  is  preserved,  forming  a  pedicle  to  the 
tumor,  but  when  this  grows  large  it  may  invade  the  broad  ligament, 
and  become  sessile.  The  tube  is  not  implicated  in  the  pedicle,  unless 
the  tumor  becomes  very  large.  The  tumors  are  generally  accompanied 
by  ascites,  which  prevents  the  formation  of  inflammatory  adhesions  as 
long  as  they  remain  small.  Sometimes  they  are  found  together  with 
myoma  of  the  uterus. 

They  may  undergo  the  same  changes  as  uterine  fibroids.  They 
may  become  cystic,  a  transformation  which  is  due  to  the  dilatation 
of  lymph-spaces  in  the  connective  tissue,  so-called  geodes,  hollows 
filled  with  a  coagulable  serous  fluid.  Such  cystic  fibroids  are  called 
cystofibromas  or  fibrocysts.  Fibroids  may  undergo  mucoid,  fatty, 
or  cancerous  degeneration,  or  become  calcified  or  ossified-  or  cartilag- 
inous. Internal  hemorrhage,  suppuration,  and  gangrene  may  occur 
in  consequence  of  torsion  of  the  pedicle  or  pressure  during  child- 
birth. 

1  H.  'C.  Coe  has  in  a  most  excellent  paper  in  Trans.  Amer.  Gyn.  Soc.,  1889,  vol. 
xiv.  pp.  170-191,  based  on  personal  observation,  discussed  "Death  from  Visceral 
Affections  after  Ovariotomy." 


DISEASES  OF  THE  OVARIES.  637 

Origin. — The  fibroma  may  originate  in  the  albnginea  or  in  a  corpus 
luteum.1 

Etiology. — The  etiology  of  ovarian  fibroids  is  unknown.  They  are 
more  common  in  young  women  than  later  in  life. 

Symptoms. — Commonly  there  are  menstrual  disturbances,  such  as 
amenorrhea,  dysmenorrhea,  or  irregular  menstruation.  The  tumor 
causes  more  pain  than  uterine  fibroids.  It  grows  very  slowly.  As- 
cites  develops  frequently  and  early.  If  the  tumor  acquires  large 
proportions,  all  the  pressure-symptoms  described  in  speaking  of  ute- 
rine fibroids  (p.  474)  may  be  developed.  As  a  rule,  the  tumor  is 
freely  movable. 

Diagnosis. — It  may  be  difficult  or  impossible  to  distinguish  an 
ovarian  fibroid  from  a  pedunculated  uterine  fibroid,  unless  both  ovaries 
can  be  felt,  which,  of  course,  excludes  an  ovarian  tumor.  The 
ovarian  tumor  causes  more  pain.  A  malignant  tumor  grows  more 
rapidly.  A  fibrocyst  of  the  ovary,  if  not  movable,  closely  resembles 
a  uterine  fibrocyst.  In  the  latter  the  sound  will,  however,  generally 
show  a  greater  depth  of  the  cavity.  A  fibrocyst  of  the  ovary  can 
hardly  be  distinguished  from  other  ovarian  cysts.  It  may,  therefore, 
often  be  necessary  to  perform  exploratory  laparotomy  before  a  positive 
diagnosis  can  be  arrived  at. 

Prognosis. — The  tumor  may  become  dangerous  by  its  size.  It  may 
oppose  an  insurmountable  obstruction  to  childbearing,  and  necessitate 
Cesarean  section.  It  may  undergo  dangerous  changes,  as  mentioned 
above.  Death  may  result  from  peritonitis,  nephritis,  uremia,  intes- 
tinal obstruction,  or  an  embolus  in  the  pulmonary  artery. 

Treatment. — Electrolysis  is  said  to  have  caused  a  diminution  of  the 
tumor,  but  it  is  not  known  if  the  result  is  permanent.  It  should 
only  be  used  if  an  operation  is  absolutely  refused.  The  true  treat- 
ment called  for  is  abdominal  or  vaginal  ovariotomy  (compare  Hyste- 
rectomy, p.  483),  which  ought  to  be  performed  as  soon  as  the  tumor 
is  found. 

II.  Papilloma. 

We  have  seen  above  (p.  580)  that  a  whole  class  of  ovarian  cysts  is 
characterized  by  the  presence  of  papillary  growths  in  the  interior, 
which  may  perforate  the  wall,  and  enter  the  peritoneal  cavity.  Simi- 
lar papillary  growths  may  develop  on  the  surface  of  a  solid  ovary 
or  the  wall  of  a  glandular  cyst. 

They  are,  as  a  rule,  accompanied  by  ascites.  They  may  be  small 
like  warts,  or  become  as  large  as  a  fist,  and  extend  to  neighboring 
organs. 

1  Those  who  are  more  particularly  interested  in  the  pathology  of  ovarian  fibroids 
will  find  an  interesting  monograph  on  the  subject  by  H.  C.  Coe  in  the  Amer.  Jour. 
Obst.,  July  and  Oct.,  1882,  vol.  xv.  p.  561,  et  seq. 


638  DISEASES  OF   WOMEN. 

Etiology. — Gonorrheal  salpingitis  has  in  several  cases  preceded  this 
formation. 

Prognosis. — It  has  a  tendency  to  become  malignant. 
Treatment. — The  treatment  consists  in  early  ovariotomy. 

III.  Sarcoma. 

Sarcoma  of  the  ovary  is  a  rare  affection. 

Pathological  Anatomy. — It  may  be  primary  or  develop  secondarily 
in  an  ovarian  cystoma.  It  is  often  bilateral.  It  forms  pink  tumors 
ranging  in  size  from  that  of  a  child's  fist  to  that  of  a  man's  head,  or 
may  even  acquire  enormous  proportions.  It  is  globular  or  oval,  and 
has  a  smooth  surface,  with  varying  consistency  according  to  the  com- 
position, the  pure  sarcomatous  growth  and  cystosarcomas  being  much 
softer  than  fibrosarcomas.  Often  small  cysts  project  slightly  from  the 
surface.  Like  other  solid  ovarian  tumors,  it  is  commonly,  and  at  an 
early  date,  accompanied  by  ascites,  which  prevents  the  formation  of 
adhesions. 

It  is  rich  in  blood-vessels,  and  may  become  cavernous,  forming 
large  cysts.  The  follicles  are  destroyed.  It  may  be  combined  with 
sarcoma  of  the  uterus. 

Spindle-celled  sarcoma  is  the  most  common  variety,  but  round- 
celled  and  mixed-celled  sarcomas  are  also  found.  The  variety  known 
as  alveolar  sarcoma  has  likewise  been  observed.  The  sarcomatous  tis- 
sue may  be  combined  with  myxomatous,  fibrous,  or  carcinomatous  tissue 
(myxosarcoma,  fibrosarcoma,  sarcoma  carcinomatosum)  or  a  new  for- 
mation of  glands  (adenosarcoma). 

The  sarcomatous  tissue  may  undergo  changes,  especially  fatty  degen- 
eration, by  which  hollows  are  formed  without  separate  walls  and  filled 
with  a  fatty  fluid.1  A  sarcoma  may  also  become  calcified.  Torsion 
of  the  pedicle  may  lead  to  internal  hemorrhage,  suppuration,  or 
gangrene. 

Etiology. — Sarcoma  has  been  found  in  new-born  children,  and  is, 
like  fibroids,  usually  found  in  young  persons.  It  may  develop  in 
a  fibroid. 

Diagnosis. — It  grows  more  rapidly  than  fibroids,  and  especially  a 
cystosarcoma  may  in  a  short  time  acquire  very  large  dimensions. 

Prognosis. — It  is  a  malignant  disease,  ending  in  death,  which  may 
be  due  to  marasmus,  peritonitis,  metastasis  in  other  organs,  or  an 
embolus  in  the  pulmonary  artery. 

Treatment. — As  soon  as  discovered  the  growth  should  be  removed 
by  ovariotomy.  The  danger  of  relapse  is  less  than  with  carcinoma. 

1  I  have  described  a  case  of  sarcoma  composed  of  cysts  with  transparent  walls, 
formed  of  spindle-cells,  and  containing  a  bloody  fluid,  in  Amer.  Jour.  Obst.,  1881,  vol. 
rxiv.  p.  890 


DISEASES  OF  THE  OVARIES.  639 

IV.  Endothelioma  (Ackermann).1 

Endotheliomas  are  malignant  tumors  which  start  as  a  prolifer- 
ation of  the  endothelial  cells  of  the  blood-  or  lymph-vessels  of  the 
ovary.  They  may  acquire  considerable  size,  and  have  a  smooth  sur- 
face studded  with  tuberosities  formed  of  a  brain-like  or  spongy  tissue. 
In  other  places  is  found  dense  connective  tissue.  They  cannot  be 
diagnosticated  from  other  solid  tumors  before  their  removal. 

Treatment — Ovariotomy. 

V.   Carcinoma. 

The  ovary  may  be  the  seat  of  medullary,  scirrhous,  or  alveolar 
(colloid)  carcinoma,  the  first  of  which  varieties  is  by  far  the  most 
common. 

Carcinoma  may  be  primary — that  is  to  say,  beginning  in  the  ovary — 
or  secondary,  invading  the  ovary  from  another  organ,  especially  the 
uterus.  The  primary  is  much  more  common  than  the  secondary,  and 
may  either  attack  the  healthy  ovary  or  an  ovarian  cystoma,  in  which 
latter  case  the  result  is  a  carcinomatous  cystoma.  Any  kind  of  cys- 
toma, myxoid  or  dermoid,  may  undergo  carcinomatous  degeneration, 
and  the  liability  to  this  transformation  is  even  considerable  (p.  586). 
We  have  seen  above  that  especially  the  glandular  variety  is  so  nearly 
related  to  the  carcinomatous  formation  that  it  may  be  very  difficult 
to  draw  the  line  of  demarkation  between  the  two  (p.  576). 

Primary  carcinoma  forms  a  tumor  varying  in  size  from  a  hen's 
egg  to  an  adult's  head.  It  is  frequently  bilateral.  In  the  beginning 
the  tumor  preserves  the  oval  form  of  the  slightly  enlarged  normal 
ovary,  but  later  it  becomes  more  globular.  It  has  a  nodular  sur- 
face, a  whitish  color,  and  varies  in  consistency  from  considerable 
firmness  to  brain-like  softness  (Fig.  328). 

At  first  the  mesoarium  forms  a  pedicle,  but  later  this  may  become 
infiltrated,  thickened,  and  hard,  and  finally  the  tumor  may  be  entirely 
sessile.  At  an  early  date  ascitic  fluid  accumulates,  which  is  often  mixed 
with  blood ;  local  peritonitis  is  of  frequent  occurrence  ;  and  the  degen- 
eration extends  to  neighboring  organs,  such  as  the  peritoneum,  the 
pelvic  connective  tissue,  the  bones,  the  lymphatic  vessels  or  glands, 
especially  those  of  the  lumbar  region,  or  to  the  uterus;  or  metastases 
appear  in  the  liver,  the  lungs,  the  spleen,  and  other  remote  parts  of 
the  body. 

It  seems  that  the  carcinomatous  degeneration  originates  in  an  atypic 
proliferation  of  the  epithelium  of  the  Graafian  follicles  or  pouches 
extending  from  the  germinal  epithelium  into  the  interior  of  the  ovary 
(p.  587). 

Secondary  carcinoma  of  the  ovary  is  brought  through  the  lym- 

1  The  name  has  been  used  in  another  sense  by  Dr.  Dixon  Jones  (p.  564). 


640  DISEASES  OF  WOMEN. 

phatics,  cancerous  epithelial  cells  being  carried  into  these  vessels,  in 

FIG.  328. 


Carcinoma  of  Ovary.1 


which  they  cause  thrombosis  and  infection  of  the  surrounding  tissue.2 
Like  other  tumors,  carcinoma  of  the  ovary  may  undergo  secondary 


FIG.  329. 


Patient  with  Carcinoma  of  Ovary,  Ascites,  Anasarca,  and  Marasmus. 

changes,  especially  fatty  degeneration,  which  leads  to  the  formation 

1  Photograph  of  specimen  from  my  operation  on  Mrs.  L.,  in  St.  Mark's  Hospital, 
on  April  12,  1894. 

2  This  is  proved  by  actual  observation  of  microscopical  specimens  from  a  carcino- 
matous  tumor  of  tbe  pelvic  floor  and  the  ovaries  belonging  to  it,  by  M.  Dixon  Jones, 
Med.  Record,  March  11,  1893,  vol.  xliii.  No.  10,  p.  295,  el  seq. 


DISEASES  OF  THE  OVARIES.  641 

of  cystic  cavities  with  ragged  walls  of  carcinomatous  tissue — a  condi- 
tion called  cystocarcinoma. 

Etiology. — Carcinoma  rarely  attacks  the  healthy  ovary,  while, 
as  we  have  seen,  it  often  occurs  in  ovarian  cystomas.  Its  cause  is 
unknown.  It  is  found  in  young  women,  and  even  in  children,  most 
commonly  near  the  two  ends  of  menstrual  activity,  puberty  or  the 
menopause. 

Symptoms. — The  disease  may  begin  as  an  acute  inflammation  or 
develop  gradually.  It  is  characterized  by  amenorrhea,  pain,  rapid 
growth,  local  peritonitis,  ascites,  edema  of  the  thighs,  and  general 
marasmus  (Fig.  329). 

Diagnosis. — It  is  distinguished  from  fibroid  and  sarcomatous  tumors 
by  the  unusually  rapid  development,  greater  pain,  edema  of  the 
thighs,  and  the  presence  of  tumors  in  Douglas's  pouch,  the  lumbar 
region,  the  omentum,  stomach,  liver,  or  spleen. 

The  ascitic  fluid  accompanying  malignant  ovarian  tumors  (carci- 
noma, sarcoma,  or  papilloma),  obtained  by  aspiration,  contains  some- 
times large  round  or  pear-shaped  cells,  with  a  large  nucleus,  either 
isolated  or  in  groups.1  Much  more  conclusive  than  aspiration  is,  how- 
ever, exploratory  incision,  which  enables  us  to  feel  the  nodules  on  the 
tumor,  and  perhaps  on  other  parts,  and  to  judge  whether  an  extirpa- 
tion should  be  attempted  or  not. 

Treatment. — If  performed  early,  ovariotomy  may  effect  a  radical 
cure.  If  the  neighboring  organs  are  implicated,  it  may  yet  give 
relief  from  painful  tension  for  several  months.  But  if  other  tumors 
are  felt  beside  the  ovary,  the  operation  is  contraindicated. 

VI.   Tuberculosis. 

Next  to  the  tubes  and  the  uterus,  the  ovary  is  the  part  of  the  geni- 
tal tract  most  commonly  affected  by  tuberculosis.  It  may  be  primary2 
or  secondary.  It  may  be  part  of  general  tuberculosis,  and  is  then 
brought  to  the  ovary  through  the  blood,  but  it  may  also  reach  the 
ovary  through  the  genital  canal. 

Pathological  Anatomy. — Miliary  tubercles  are  rarely  found.  The 
affection  may  be  limited  to  the  surface  or  invade  the  whole  organ. 
The  ovary  is  then  somewhat  enlarged,  soft,  and  contains  cheesy  de- 
posits ranging  in  size  from  that  of  a  millet-seed  to  that  of  a  marble. 
These  tuberculous  nodules  may  soften  and  rupture  into  the  peritoneal 
cavity,  causing  peritonitis.  The  surface  of  the  ovary  is  commonly 
covered  with  layers  of  inflammatory  exudation  and  adhesions. 

Symptoms. — The  symptoms  are  those  of  chronic  oophoritis. 

Diagnosis. — The  disease  can  only  be  diagnosticated,  if  swelling  of 

1  Garrigues,  Diagnosis  of  Ovarian  Oysts,  pp.  94-97. 

2  Dr.  G.  M.  Tuttle  of  New  York  has  reported  a  case  of  apparently  primary  tuber- 
culosis of  the  ovary  in  Aimer.  Jour.  Obst.,  Jan.,  1890,  xxiii.  p.  68. 

41 


642  DISEASES  OF  WOMEN. 

the  ovary  is  combined  with  pulmonary  tuberculosis  or  local  tuber- 
culosis of  the  visible  part  of  the  genital  canal,  or  if  the  discharge 
from  the  uterus  contains  cheesy  masses  and  tubercle-bacilli. 

Treatment. — If  the  affection  is  primary,  salpingo-oophorectomy  may 
lead  to  a  cure.  If  it  is  combined  with  pulmonary  tuberculosis,  and 
the  disease  has  been  checked  in  the  lungs,  the  removal  of  the  append- 
ages is  still  indicated.  If  it  is  allied  to  a  similar  affection  of  the 
tube  and  the  uterus,  hysterectomy  may  be  added  (p.  491).  Even 
tubercular  peritonitis  may  be  cured  by  the  operation.  On  the  other 
hand,  the  operation  is  contra-indicated  as  long  as  the  disease  spreads 
in  the  lungs.  If  no  radical  cure  is  possible,  the  usual  medical  and 
hygienic  treatment  is  all  we  have  to  rely  on. 


CHAPTER    VI. 

OOPHOBALGIA. 

THE  ovary  may  be  the  seat  of  neuralgia.  In  most  cases  this  forms 
only  part  of  hysteria,  but  the  disease  may  be  found  in  women  who  show 
no  other  symptoms  of  that  affection.  It  may  be  of  malarial  origin. 

The  left  ovary  is  affected  much  more  frequently  than  the  right,  for 
which  circumstance  we  may,  perhaps,  find  an  explanation  in  its  con- 
tact with  the  rectum,  the  contents  of  which  are  apt  to  press  on  the 
ovary  on  this  side,  or  the  different  disposition  and  construction  of  the 
ovarian  vein  on  this  side  (p.  74).  Sometimes  the  affection  is  bilateral. 
The  pain  is  spontaneous,  or  may  be  produced  by  pressure  on  the 
ovary.  It  is  felt  in  the  hip,  shooting  back  to  the  lumbar  region  or 
down  the  leg,  and  is  so  severe  that  the  patient  can  neither  be  moved 
nor  stand.  Very  often  it  is  combined  with  hemianaBSthesia  of  the 
corresponding  side  and  hystero-epileptic  seizures.  Pressure  on  the 
ovary  produces,  first,  cardialgia  and  vomiting ;  next,  palpitations,  with 
frequent  pulse  and  globus  hystericus;  and,  finally,  often  a  hissing 
sound  in  the  corresponding  ear,  pain  in  the  temple,  darkening  of  the 
eyesight,  loss  of  consciousness,  and  convulsions. 

While  pressure  on  the  ovary  may  produce  such  an  attack,  it  can 
also  check  a  spontaneous  one. 

Diagnosis. — In  chronic  oophoritis  the  ovary  is  enlarged,  and  often 
uneven  and  fastened  by  adhesions. 

Treatment. — The  treatment  consists  in  rest,  anodynes,  galvanism, 
faradization  with  the  secondary  current  of  high  tension  (p.  230),  and 
tonic  and  antihysteric  remedies.  If  the  disease  is  malarial,  it  yields 
to  large  doses  of  quinine.1  Oophorectomy  has  sometimes  a  marked 
beneficial  effect,  but  is  in  many  cases  fruitless. 

1  Case  of  H.  C.  Coe,  Amer.  Jour.  Med.  Sci.,  April,  1891,  vol.  ci.  p.  365. 


PART  VII. 

DISEASES  OF  THE  PELVIS. 

UNDER  this  title  we  describe  the  affections  of  the  peritoneum,  the 
connective  tissue,  and  the  blood-  and  lymph- vessels  of  the  true  pelvis, 
•including  the  ligaments  of  the  uterus. 


CHAPTER    I. 
MALFORMATIONS. 

IN  speaking  of  the  uterus  (p.  394)  we  have  mentioned  that  latero- 
position  is  due  to  an  uneven  development  of  the  two  broad  ligaments, 
anteposition  to  defective  development  of  the  parts  situated  in  front 
of  the  uterus,  and  retroposition  to  a  similar  defect  in  those  behind  it. 

Perhaps  some  cases  of  congenital  anteflexion  and  anteversion  orig- 
inate in  too  great  shortness  of  the  round  ligaments. 

The  peritoneal  pouch,  which  in  the  fetus  forms  the  canal  of 
Nuck,  and  normally  is  transformed  to  a  fibrous  string,  may  remain 
open.  It  may  either  remain  in  connection  with  the  abdominal  cavity 
or  be  closed  at  the  upper  end  and  become  the  seat  of  hydrocele,  or 
form  a  sheath  around  the  round  ligament,  which  must  be  pushed  back 
in  Alexander's  operation  (pp.  59,  262,  and  449). 


CHAPTER    II. 
ANEURYSM  OF  THE  UTERINE  ARTERY. 

I  AM  not  aware  that  more  than  one  case  of  aneurysm  of  the  ute- 
rine artery  has  been  reported.1  Upon  vaginal  examination  there  was 
found  a  pulsating  tumor  in  the  pelvis  of  the  size  of  a  hazelnut, 
which  was  diminished  by  pressure,  but  refilled  again  each  time  press- 
ure was  discontinued.  It  gave  a  subjective  sensation  of  throbbing. 
It  was  supposed  to  be  due  to  the  use  of  leeches  in  the  vagina,  and 

1  Mare,  Excerpta  Medica.  No.  2,  Nov.,  1891. 

643 


644  DISEASES  OF  WOMEN. 

might,  perhaps,  also  be  due  to  childbirth.  The  treatment  recom- 
mended is  galvanopuncture,  with  the  positive  pole  in  the  tumor, 
or  forcipressure. 


CHAPTER   III. 
DISEASES  OF  THE  BROAD  LIGAMENT. 

A.  Varicocele  of  the  Broad  Ligament,  or  Parovarian  Varicocele. 

VARICOCELE  in  the  female  corresponds  to  the  same  condition  in  the 
male,  but  the  different  anatomical  relations  constitute  rather  consider- 
able differences  between  the  two.  While  in  man  the  veins  of  the 
testis  follow  an  almost  perpendicular  course,  those  of  the  ovary  are 
nearly  horizontal.  The  spermatic  veins  soon  form  a  single  trunk, 
whereas  the  pampiniform  plexus  in  woman  communicates  freely  with 
the  uterine,  the  vaginal,  and  the  vesical  plexus.  There  will,  therefore, 
be  less  tendency  to  the  disease  in  woman  than  in  man.  As  a  matter 
of  fact,  it  is  about  three  times  less  common  in  female  cadavers  than 
in  male,  and  is  rarely  recognized  in  the  living  subject,  although  we 
may  be  sure  that  the  swelling  must  have  been  much  larger  during 
the  patient's  lifetime  than  after  death. 

By  varicocele  we  do  not  mean  the  enlargement  of  veins  in  the 
broad  ligament  which  accompanies  tumors,  especially  uterine  fibroids, 
but  an  isolated  swelling  of  the  ovarian  veins,  implicating  more  or  less 
the  other  veins  of  the  broad  ligament,  It  has  been  divided  into  supe- 
rior parovarian  varicocele  when  it  is  situated  between  the  ovary  and 
the  tube,  and  inferior  parovarian  varicocele,  when  it  is  found  below  the 
ovary.  It  may  reach  the  size  of  a  hen's  egg,  and  is  composed  of  a 
conglomeration  of  veins,  the  walls  of  which  are  often  thickened,  and 
which  may  contain  phleboliths.  It  is  much  more  common  on  the  left 
side,  but  may  be  found  on  the  right  or  on  both,  the  preponderance  on 
the  left  side  being  without  doubt  due  to  the  lack  of  a  valve  in  the 
left  ovarian  vein,  and  to  the  fact  that  it  opens  at  right  angles  into  the 
renal  vein  (p.  74). 

Etiology. — The  condition  is  probably  due  to  stibin volution  after 
confinement ;  a  relaxed  condition  of  the  tissues  following  a  low  state 
of  the  general  health  ;  an  original  weakness  of  the  walls  of  the  veins ; 
pressure  from  fecal  accumulation  in  the  sigmoid  flexure,  which  lies  in 
front  of  the  ovarian  vein  ;  or  displacements  of  the  uterus,  especially 
retroversion  and  retroflexion,  which  interfere  with  the  free  return  of 
the  blood  througli  the  infundibulopelvic  ligament. 

Symptoms. — The  most  prominent  symptom  is  pain  of  a  peculiar 
dull,  aching  character,  extending  up  the  side  to  the  region  of  the  kid- 
iiey.  The  pain  disappears  when  the  patient  is  in  the  horizontal  posi- 


DISEASES  OF  THE  PELVIS.  645 

tion,  and  is  increased  by  standing  erect.  By  bimanual  examination 
with  one  finger  in  the  rectum  a  distinct  doughy  tumor  or  knotted 
swollen  vessels  may  be  felt  in  the  broad  ligament. 

Prognosis. — Some  patients  suffer  so  much  that  they  are  unable  to 
stand  or  walk,  and  are  bedridden  invalids  for  years.  The  dilated 
veins  may  rupture,  and  form  a  hematocele  or  hematoma  (see  below). 

Diagnosis. — Salpingitis  causes  a  sausage-shaped  tumor ;  odphoritis 
is  harder  and  more  painful ;  cellulitis  and  pelvic  peritonitis  have  more 
diffuse  contours,  and  none  of  them  becomes  smaller  in  the  recumbent 
position.  A  swollen  vein  may  be  confounded  with  a  swollen  ureter, 
but  in  the  latter  condition  other  symptoms  of  a  pathological  state  of 
the  uropoietic  organs  are  present. 

Treatment. — If  the  condition  is  recent,  hot  douches,  tincture  of  iodine, 
ichthyol  glycerin,  or  faradic  electricity,  combined  with  frequent  rest 
in  a  recumbent  position  and  attention  to  the  bowels,  may  effect  a  cure. 
If  it  is  old  enough  to  have  produced  permanent  dilatation  of  the 
veins  and  thickening  of  their  walls,  nothing  is  likely  to  be  of  avail 
except  an  extirpation  of  the  affected  part  of  the  broad  ligament, 
together  with  the  tube  and  ovary ;  which  may  be  done  by  tying  it 
with  the  cobbler's  stitch  or  some  other  form  of  a  chain-ligature,  and 
cutting  the  parts  away  above  the  ligature.1 

B.   Cysts  of  the  Broad  Ligament. 

Not  every  cyst  situated  in  the  broad  ligament  is  a  cyst  of  the  broad 
ligament.  We  have  seen  above  (p.  585)  that  ovarian  tumors  may 
develop  downward  into  the  broad  ligament  and  even  far  beyond  its 
base.  A  Graafian  follicle  or  a  corpus  luteum  may  form  such  a  cyst. 
By  a  cyst  of  the  broad  ligament  is  meant  a  cyst  developed  in  the 
broad  ligament  outside  of  the  ovary.  Such  cysts  are  sometimes 
called  parovarian  cysts,  but  this  name  is  not  quite  correct,  for  the 
parovarium  is  a  definite  organ  found  in  a  definite  locality,  and,  if  it 
is  true  that  such  cysts  may  develop  in  it,  it  is  no  less  true  that  they 
may  develop  in  any  other  part  of  the  broad  ligament.  The  schematic 
figure  330  gives  a  good  idea  of  the  locality  of  such  cysts. 

Cysts  of  the  broad  ligament  are  much  rarer  than  ovarian  cysts. 
As  a  rule,  they  are  monocystic,  but  exceptionally  polycystic  tumors 
of  this  origin  have  been  found.  Commonly,  they  do  not  exceed  the 
size  of  a  pregnant  uterus  at  six  months'  gestation,  but  exceptionally 
they  may  become  enormous. 

1  The  disease  has  been  described,  with  report  of  four  cases  in  which  Inparotomy 
•was  performed  successfully,  by  A.  P.  Dudley  of  New  York  in  the  N.  Y.  Med.  Jour., 
Aug.  11  and  18,  1888 — a  paper  that  has  been  severely,  and  in  my  opinion  rather 
unjustly,  criticised  by  Coe  in  Amer.  Jour.  Obst.,  May,  1889,  vol.  xxii.  p.  504.  I  have 
myself  operated  on  a  case  of  this  kind — Mrs.  H.,  St.  Mark's  Hospital,  Feb.  19,  1894. 
The  left  broad  ligament  formed  a  conglomeration  of  tortuous  dark  bine,  almost  black 
veins,  each  as  thick  as  a  lead  pencil,  situated  between  the  uterus  and  the  tube. 


646 


DISEASES  OF  WOMEN. 


As  a  rule,  the  wall  is  so  thin  as  to  be  translucent  or  transparent, 
but  in  exceptional  cases  the  cyst  may  look  like  a  uterine  growth  on 
account  of  a  thick  layer  of  smooth  muscle-fibers.  The  wall  is  com- 
posed of  the  peritoneum  with  its  endothelium ;  a  layer  of  connective 
tissue  containing  some  plain  muscle-fibers ;  often  glands,  which  do  not 
open  into  the  interior ;  and  very  few  blood-vessels,  which  gives  it  a 


Diagram  of  the  Structures  in  and  adjacent  to  the  Broad  Ligament  (Doran) :  1,  framework  of  the 
parenchyma  of  the  ovary,  seat  of  1  a,  simple  or  glandular  multilocular  cyst ;  2,  tissue  of 
hilum  with  3,  papillary  cyst l;  4,  broad-ligament  cyst  independent  of  parovarium  and  Fallo- 
pian tube ;  5,  similar  cyst  in  broad  ligament,  above  the  tube,  but  not  connected  with  it ; 
6,  similar  cyst  developed  close  to  7,  ovarian  flmbria  of  tube ;  8,  the  hydatid  of  Morgagni ; 
9,  cyst  developed  from  horizontal  tube  of  parovarium ;  10,  the  parovarium :  the  dotted  lines 
represent  the  inner  portion,  always  more  or  less  obsolete  in  the  adult ;  11,  small  cyst  devel- 
oped from  a  vertical  tube :  12,  Gartner's  duct ;  13,  track  of  the  same  in  the  uterine  wall. 

white  color.  Its  interior  surface  is  smooth  or  wrinkled,  but  has  no 
glandular  formations,  and  is  covered  with  a  single  layer  of  vibratile, 
low  columnar  or  flat  epithelium.  As  a  rule,  these  cysts  extend  right 
up  to  the  tube,  that  becomes  imbedded  in  the  wall  without  mesosal- 
pinx.  Like  ovarian  tumors,  they  may  develop  below  the  broad  liga- 
ment, and  come  to  lie  below,  in  front  of,  or  behind  the  peritoneum. 
They  may  become  so  large  as  to  be  much  more  abdominal  than  pelvic 
tumors. 

The  fluid  is  normally  watery,  nearly  colorless,  and  alkaline  or 
neutral.  It  does  not  coagulate  spontaneously,  nor  to  any  extent  by 
heat  before  adding  an  acid.  It  contains  a  few  cells  and  Bennett's  large 
and  small  corpuscles  (Figs.  301,  302,  and  308,  pp.  577,  578).  But 
in  exceptional  cases  a  thick  colloid  fluid  has  been  found  in  such  cysts. 

Papillary  and  dermoid  cysts  may  also  develop  in  the  broad  ligament. 

As  a  rule,  cysts  of  the  broad  ligament  are  sessile,  but  sometimes 

1  This  theory  about  the  origin  of  the  two  kinds  of  ovarian  cysts  is  not  generally 
admitted. 


DISEASES  OF  THE  PELVIS.  647 

the  ligament  forms  a  pedicle,  which  may  even  become  twisted,  an 
accident  that  may  lead  to  gangrene  of  the  tuinor. 

These  tumors  are  found  in  the  period  of  sexual  maturity.  They 
grow  very  slowly.1  They  do  not  impair  the  general  health,  and  give 
rise  to  no  symptoms  except  by  their  bulk. 

Diagnosis. — A  small  cyst  of  the  broad  ligament  may  be  felt  in  the 
pelvis  separate  from  the  ovary  and  tilting  the  uterus  over  to  the 
opposite  side.  It  may  be  so  like  hematoma  that  it  cannot  be  distin- 
guished from  it  except  by  the  history,  the  latter  developing  rapidly, 
and  being  reabsorbed  after  some  time.  The  distinction  from  ovarian, 
especially  intraligamentous,  and  other  abdominal  cysts  may  be  very 
difficult.  The  leading  points  are  the  slow  development,  slight  pain, 
absence  of  cachexia,  the  low  seat,  absence  of  solid  masses,  a  very  dis- 
tinct fluctuation- wave,  flatness  in  front,  and  greater  fullness  in  the 
flanks. 

It  is  impossible  to  tell  for  sure,  by  the  fluid  alone,  whether  a  tumor 
is  ovarian  or  a  cyst  of  the  broad  ligament,  although  the  presumption 
may  be  strongly  in  favor  of  one  or  the  other2 :  both  ovarian  cysts  and 
cysts  of  the  broad  ligament  may  have  serous  or  colloid  contents,  but 
the  latter  is  common  in  ovarian  cysts,  rare  in  extra-ovarian,  while  the 
watery  is  common  in  extra-ovarian,  rare  in  ovarian  cysts.  Still,  it 
may  be  found,  not  only  in  true  monocysts,  but  in  multilocular 
cystomas  of  the  ovary. 

Treatment. — Small  tumors  of  this  kind  should  be  let  alone.  When 
by  their  bulk  they  become  troublesome,  the  best  thing  to  do  is  to  re- 
move them  exactly  like  an  ovarian  tumor.  Sometimes  there  is  a  pedicle, 
and  sometimes  one  can  be  made  of  the  peritoneal  covering  during  the 
operation.  Enucleation  is,  as  a  rule,  easy.  If  it  meets  with  difficul- 
ties, the  sac  should  be  cut  open  and  the  left  hand  introduced  to  help 
the  right  hand  separate  the  cyst  from  the  peritoneum.  After  the  enu- 
cleation  the  empty  shell  may  be  tied  as  a  pedicle  in  one  or  more  sec- 
tions, or  the  edges  may  be  stitched  together  with  catgut,  or  they  may  be 
brought  together  as  a  purse  and  fastened  to  the  abdominal  wound. 
The  cavity  is  packed  with  iodoform  gauze,  ancf  will  fill  by  granula- 
tion, but,  as  a  rule,  only  with  suppuration.  If  the  tumor  cannot  be 
enucleated,  the  whole  sac  may  be  fastened  to  the  abdominal  wound 
(marsupialization).  Redundant  tissue  is,  of  course,  cut  away  in  all 
these  procedures. 

Another  way  of  operating  is  simply  to  cut  out  a  large  circular 
piece  of  the  wall  and  close  the  abdomen. 

These  cysts  used  to  be  treated  by  tapping  or  aspiration,  and  their 

1 1  have,  many  years  ago,  assisted  in  aspirating  one  that  had  been  tapped  five  years 
before  by  W.  L.  Atlee,  and  in  that  time  had  not  become  larger  than  the  uterus  at  the 
end  of  six  months'  gestation. 

2  Garrigues,  Diagnosis,  etc.,  pp.  49-55. 


648  DISEASES  OF  WOMEN. 

innocuous  nature  and  the  slowness  to  refill  of  most  of  them  are  indeed 
great  inducements  to  use  that  kind  of  treatment ;  but  since  it  has  been 
discovered  that  some  of  them  are  papillomatous,  and  the  radical  ope- 
ration in  most  cases  easy  and  safe,  extirpation  is  preferred  by  most 
gynecologists. 

If  the  ovary  and  tube  are  healthy  and  placed  so  that  they  need  not 
be  removed,  they  should  be  left  behind. 

C.  Solid  Tumors  of  the  Broad  Ligament. 

Besides  uterine  fibroids  which  grow  in  between  the  layers  of  the 
broad  ligament,  and  of  which  enough  has  been  said  in  speaking  of 
that  disease,  the  broad  ligament  is  occasionally  the  seat  of  solid  tumors 
which  take  their  origin  in  the  ligaments  themselves.  Thus,  myomas, 
fibromas — sometimes  melting  to  fibrocysts — lipomas,  and  sarcomas, 
have  been  observed.  Such  tumors  may  push  the  vagina  before  them 
and  protrude  into  the  vulva,  or  grow  out  through  the  greater  sciatic 
foramen,  simulating  a  hernia. 

All  solid  tumors  of  the  broad  ligament  should  be  removed  by 
laparotomy  as  soon  as  discovered. 


CHAPTER   IV. 
DISEASES  OF  THE  ROUND  LIGAMENT. 

IN  an  earlier  part  of  this  work  (p.  256)  we  have  said  that  any 
part  of  the  round  ligament  may  become  the  seat  of  a  fibroma,  and 
that  this  occurs  more  frequently  outside  than  inside  of  the  pelvis. 
The  fibrous  tissue  is  commonly  blended  with  muscular,  myxomatous, 
or  sarcomatous  tissue,  constituting  a  myofibroma,  myxofibroma,  or 
fbrosarcoma.  In  one  case  the  lymphatics  were  much  distended 
(fibroma  lymphangiectodes). 

The  affection  is  much  more  common  on  the  right  side  than  on  the 
left.  The  diagnosis  may  be  very  difficult.  The  treatment  consists 
in  early  extirpation. 

CHAPTER  V. 
•  DISEASES  OF  THE  SACRO-UTERINE  LIGAMENT. 

WE  have  seen  above  (p.  426)  that  inflammation  of  the  sacro-uterine 
ligament  is  a  chief  cause  of  anteflexion  of  the  uterus.  One  or  both 
ligaments  are  swollen,  tender  on  pressure,  and  become  shortened 
through  cicatricial  contraction. 


DISEASES  OF  THE  PELVIS.  649 

The  usual  antiphlogistic  treatment,  especially  ichthyol  glycerin, 
tincture  of  iodine,  hot  douche,  and  the  galvanic  current,  is  indicated, 
and  often  yields  good  results  in  fresh  cases ;  and  even  a  chronic  short- 
ening may  be  overcome  by  means  of  vaginal  packing  (p.  178). 

Since  these  ligaments  form  the  chief  support  of  the  uterus  (p.  55), 
their  loss  of  tonus  and  elongation,  usually  due  to  childbirth,  are  prin- 
cipal factors  in  the  production  of  prolapse  of  the  uterus  (p.  454).  The 
loss  of  tonicity  may  perhaps  be  remedied  by  the  use  of  the  faradic 
current  or  massage.  If  not,  recourse  must  be  had  to  pessaries,  sup- 
porters, or  the  operations  indicated  for  prolapse  (p.  457). 


CHAPTER  VI. 
PELVIC  HEMORRHAGE. 

INTERNAL  hemorrhage  from  the  genitals  and  the  parts  near  them 
takes  place  in  three  ways,  differing  widely  from  one  another  as  to  fre- 
quency, anatomy,  danger,  and  treatment,  and  which  it  is,  therefore, 
appropriate  to  designate  by  three  different  names  and  to  describe 
apart  from  one  another.  Since,  however,  most  authors  follow 
a  different  course  in  this  respect,  it  is  necessary  to  add  the  other  names 
under  which  the  described  conditions  are  known. 

The  blood  may  be  poured  freely  into  the  peritoneal  cavity.  We 
call  this  simply  intraperitoneal  hemorrhage,  but  most  writers  class  it 
with  the  second  condition,  and  call  it  non-encysted  hematocele  or 
cataclysmic  hematocele.  Secondly,  the  blood  may  enter  the  peri- 
toneal cavity,  and  become  limited  by  inflammatory  exudation,  so  as  to 
form  a  tumor.  We  call  this  hematocele,  but  it  has  been  designated 
as  pelvic  hematocele,  intraperitoneal  hematocele,  or  true  hematocele 
(always  comprising  the  free  intraperitoneal  hemorrhage).  Finally, 
the  extravasated  blood  may  be  situated  in  the  connective  tissue  of 
the  broad  ligaments,  the  pelvis,  and  the  abdomen.  This  condition  we 
designate  as  hematoma,  but  it  is  also  called  extraperitoneal  hematocele, 
false  hematocele,  pseudohematocele,  or  thrombus.  (Compare  Throm- 
bus of  the  Vulva,  p.  276.) 1 

A.  Intraperitoneal  Hemorrhage. 

If  a  large  amount  of  blood  is  poured  rapidly  into  the  healthy  peri- 
toneal cavity,  it  meets  with  no  resistance,  the  intestines  are  pushed 
aside,  and  the  abdominal  wall  becomes  distended. 

Etiology. — Most  cases  of  abdominal  hemorrhage  are  traumatic  and 

1  Kosenwasser  of  Cleveland,  Ohio,  unites  the  two  last  condition,  under  the  name  of 
circumscribed  or  limited,  hemorrhage,  opposed  to  the  first,  which  he  calls  free  hemor- 
rhage (Trans.  Amer.  Obstetricians  and  Gynecologists,  1893). 


650  DISEASES  OF  WOMEN. 

due  to  rupture  of  the  liver,  or  they  may  be  caused  by  the  rupture  of 
an  aneurysm  of  the  abdominal  aorta  or  the  celiac  axis.  In  gyneco- 
logical practice  they  are  nearly  always  brought  about  by  tubal  preg- 
nancy with,  or  oftener  without,  rupture  of  the  tube,  and  sometimes 
by  rupture  of  a  dilated  vein,  such  as  those  forming  a  varicocele  or 
accompanying  a  uterine  fibroid,  or  by  hemorrhage  from  a  badly 
secured  pedicle,  or  by  adhesions  torn  during  laparotomy. 

Symptoms. — The  condition  is  characterized  by  sudden  pain  in  the 
abdomen  ;  a  sensation  of  a  warm  internal  current ;  faiutness ;  nausea ; 
vomiting ;  a  frequent,  small,  or  imperceptible  pulse ;  a  subnormal  tem- 
perature ;  difficult  respiration  ;  pallor ;  a  cold,  clammy  skin  ;  and  often 
discharge  of  blood  from  the  vagina.  Consciousness  is  preserved  and 
the  patient  feels  that  she  is  dying. 

Diagnosis. — We  have  only  these  rational  symptoms  of  internal 
hemorrhage  to  go  by.  No  tumor  can  be  felt,  and  we  cannot  wait  for 
a  dull  percussion-sound  or  the  feel  of  fluctuation. 

Prognosis. — The  condition  is  absolutely  fatal  unless  the  hemorrhage 
is  arrested  by  surgical  means. 

Treatment. — The  indication  is  the  same  as  for  any  other  serious 
hemorrhage  accessible  to  the  surgeon's  knife :  laparotomy  offers  the 
only  chance  of  rescue  for  the  patient.  Clots,  fluid  blood,  and  foreign 
substances,  such  as  a  fetus,  must  be  removed  from  the  peritoneal  cav- 
ity, bleeding  vessels  tied,  or  diseased  appendages  removed  on  the 
affected  side.  It  is  even  recommended,  in  cases  of  a  ruptured  fetal 
sac,  not  only  to  stitch  up  the  tear  in  the  tube,  but  to  combine  with  it 
the  ligation  of  both  the  ovarian  and  uterine  artery  in  their  continuity. 

B.  Hematocele. 

Hematocele  is  an  encysted  effusion  of  blood  in  the  peritoneal  cav- 
ity of  the  pelvis. 

Pathological  Anatomy. — As  a  rule,  the  blood  is  found  in  Douglas's 
pouch,  but  if  the  amount  is  large,  it  rises  more  or  less  above  the 
brim  of  the  pelvis,  and  may  reach  as  far  up  as  the  umbilicus.  At 
first  it  lies  behind  the  uterus,  and  is,  therefore,  called  a  retro-uterine 
hematocele.  If  later  it  surrounds  that  viscus,  it  is  designated  as 
circumuterine.  If  Douglas's  pouch  is  closed  by  adhesions,  the  blood 
accumulates  in  front  of  and  above  the  uterus,  which  condition  is 
named  ante-uterine  hematocele,  and  is,  of  course,  much  rarer  than  the 
other  varieties. 

The  blood  is  at  first  pure  and  thin,  but  becomes  coagulated,  in- 
spissated, tarry,  and,  still  later,  sometimes  mixed  with  pus  or  sanies. 
Through  adhesive  peritonitis  the  intestinal  knuckles  are  glued  to- 
gether, and  plastic  lymph  is  poured  out  and  converted  into  tissue, 
forming  a  roof  over  the  extravasated  blood,  which  in  places  is  finger- 
thick  and  shuts  it  off  from  the  peritoneal  cavity. 


DISEASES  OF  THE  PELVIS.  651 

The  blood  may  be  derived  from  the  ovaries,  the  tubes,  the  uterus, 
the  broad  ligaments,  the  peritoneum,  or  a  fetal  sac. 

If  it  is  a  case  of  tubal  pregnancy,  the  fetus  is  found  only  in  a 
small  minority  of  cases,  which  shows  that  it  becomes  absorbed  ;  but 
on  microscopical  examination  we  always  find  villi  chorii,  which  are 
entirely  characteristic  of  an  impregnated  ovum. 

Sometimes  peritonitic  adhesions  exist  before  the  hemorrhage  takes 
place,  or  repeated  hemorrhage  may  occur  under  the  already  formed 
roof. 

Etiology. — Hematocele  is  a  rather  rare  disease.  It  is  found  at  the 
age  of  sexual  maturity,  most  frequently  in  persons  between  twenty-five 
and  thirty-six  years  of  age.  We  may  distinguish  two  chief  forms,  of 
which  one  is  brought  about  by  rupture  of  some  organ,  while  the  other 
is  due  to  menstrual  fluid  entering  the  peritoneal  cavity  through  the 
abdominal  ostium  of  the  tube.  By  far  the  most  common  cause  is  a 
tubal  pregnancy  rupturing  into  the  peritoneal  cavity.  Hematosal- 
pinx  is  more  apt  to  cause  fatal  hemorrhage  in  rupturing  than  the 
formation  of  a  tumor.  Hemorrhagic  salpingitis  may  furnish  the 
blood.  There  may  be  closure  of  the  uterine  end  of  the  tube  or  atresia 
of  the  uterus  or  vagina.  In  rare  cases  the  hematocele  is  caused  by 
bleeding  from  an  apoplectic  Graafian  follicle  or  a  hematoma  in  the 
stroma  of  the  ovary  (p.  554).  A  hematoma  of  the  broad  ligament 
may  secondarily  burst,  and  pour  its  contents  into  the  peritoneal  cavity. 
A  ruptured  vein  is  more  likely  to  cause  a  speedily  fatal  hemorrhage. 
Torn  peritonitic  adhesions  may  cause  hematocele — e.  g.  when  an 
adherent  retroflexed  uterus  is  forcibly  replaced  (p.  449),  or  the  adhe- 
sions may  give  rise  to  a  bleeding  in  their  interior  by  the  same  process 
as  that  which  in  pachymeningitis  leads  to  the  formation  of  a  hema- 
toma of  the  dura  mater.  This  condition  is  called  hemorrhagic  pachy- 
peritonitis. 

The  formation  of  a  hematocele  is  often  closely  allied  to  menstrua- 
tion. It  is  not  only  when  the  genital  canal  is  closed  that  regurgita- 
tion  takes  place,  but  lifting  of  heavy  weights,  violent  exercise,  coition, 
and  exposure  to  cold  during  the  menstrual  period  may  have  the  same 
effect. 

Systemic  diseases,  such  as  scarlet  fever,  small-pox,  purpura,  and 
icterus  gravis,  may  cause  such  changes  in  the  composition  of  the 
blood,  and  weaken  the  walls  of  the  pelvic  blood-vessels  so  much,  that 
they  give  way  and  allow  the  blood  to  escape  into  the  peritoneal  cavity. 

Symptoms. — Sometimes  there  are  premonitory  symptoms.  If  the 
hematocele  is  due  to  ovarian  or  tubal  disease,  there  will,  as  a  rule,  be 
a  history  of  dysmenorrhea  and  pain  in  the  pelvis.  If  the  genital 
canal  is  closed,  the  patient  has  never  menstruated,  or  at  least  not  for 
a  long  time,  and  may  have  had  monthly  molimina.  In  extra-uterine 
pregnancy  there  may  be  signs  of  pregnancy,  expulsion  of  decidua,  and 


652  DISEASES  OF  WOMEN. 

previous  attacks  of  pain.  Metrorrhagia  or  menorrhagia  may  have 
been  present  as  a  sign  of  some  abnormal  condition  of  the  internal 
genitals ;  or  the  patient  may  recently  have  gone  through  one  of  the 
above-named  systemic  diseases.  In  other  cases  the  onset  may  be  sudden 
and  without  warning.  How  severe  it  will  be  depends  on  the  amount 
of  blood  that  has  extravasated,  and  the  rapidity  with  which  it  escapes. 
There  is  always  a  sudden  pain  in  the  pelvis,  to  which  may  be  added 
faintness,  nausea,  vomiting,  a  more  or  less  rapid  and  weak  pulse,  and 
swelling  of  the  abdomen,  due  to  tympanites.  Instinctively  the  patient 
avoids  all  movements,  and  lies,  as  a  rule,  on  her  back.  If  she  is 
menstruating,  the  flow  may  stop,  or,  on  the  other  hand,  outside  of 
the  menstrual  period  there  may  come  a  bloody  discharge  from  the 
vagina. 

This  stage  of  hemorrhage  is  the  next  day  followed  by  one  of 
inflammatory  reaction,  with  a  chill,  a  pulse  beating  100  to  140  in  the 
minute,  and  a  temperature  of  102°— 104°  F.  But  this  stage  is  like- 
wise of  short  duration.  As  soon  as  the  fluid  is  well  encysted  pulse 
and  temperature  return  to  the  normal  standard,  and  the  pain  abates. 

The  third  stage  is  that  of  absorption,  in  which  the  coagulated  and 
inspissated  blood  is  gradually  liquefied  and  taken  up  into  the  circu- 
lation. Only  in  exceptional  cases  suppuration  or  septicemia  super- 
venes. If  rupture  occurs,  the  contents  are  most  frequently  evacuated 
through  the  rectum,  more  rarely  through  the  vagina,  and  still  more 
so  through  the  bladder.  They  may  also  enter  the  free  peritoneal 
cavity.  During  the  time  of  resorption  there  is  often  a  discharge  of 
thick,  dark  blood  from  the  vagina,  which  probably  is  some  of  the 
extravasated  blood  that  finds  its  way  out  through  the  tube  and  uterus, 
while  others  think  it  is  of  uterine  origin  and  due  to  hyperemia. 

If  the  amount  of  blood  in  the  peritoneal  cavity  is  large,  it  may 
give  rise  to  pressure-symptoms,  such  as  constipation,  retention  of 
urine,  tenesmus,  uremia,  neuralgia,  edema  of  the  legs,  and  rarely 
phlebitis.  Sometimes  jaundice  is  developed,  and  the  urine  contains 
urobilin,  causing  green  fluorescence  when  chloride  of  zinc  in  ammo- 
niacal  solution  is  added. 

By  vaginal  examination  at  first  a  soft  mass,  and  later  a  tumor,  is 
felt  filling  Douglas's  pouch  and  extending  more  or  less  upward  toward 
the  umbilicus.  The  examination  is  best  made  with  one  finger  in  the 
rectum,  one  in  the  vagina,  and  the  other  hand  on  the  abdomen. 
Parts  of  the  tumor  may  be  hard  and  others  fluctuating.  It  bulges 
with  a  round  end  into  the  vagina,  which,  as  well  as  the  vaginal  portion, 
may  be  seen  to  be  in  an  anemic  condition.  The  uterus  is  pushed  for- 
ward and  upward  against  the  symphysis.  By  means  of  the  sound  it 
can  be  ascertained  that  the  fundus  lies  upward  and  forward.  If 
Douglas's  pouch  was  closed  before  the  attack,  the  tumor  is  situated 
in  front  of  the  uterus,  and  tilts  it  backward  against  the  sacrum.  If 


DISEASES  OF  THE  PELVIS.  653 

it  was  partially  closed  by  adhesions,  the  lower  end  of  the  tumor  is 
irregular. 

In  the  cachectic  form  of  hematocele  the  bleeding  may  take  place 
slowly,  and  in  certain  cases,  depending  on  menstruation,  there  may 
be  a  monthly  exacerbation,  with  increase  in  the  size  of  the  tumor. 

Diagnosis. — The  diagnosis  is,  as  a  rule,  not  difficult.  The  general 
condition  is  not  so  alarming  as' in  unlimited  intraperitoneal  hemor- 
rhage. Hematoma  does  Aiot  form  so  large  a  tumor,  is  not  accom- 
panied by  vaginal  discharge  or  peritonitis,  is  lateral  and  pushes  the 
uterus  over  to  the  opposite  side,  and  is  absorbed  sooner.  Pelriperito- 
nitis  is  ushered  in  with  fever,  while  in  hematocele  it  comes  a  day 
later.  The  well-defined  tumor  is  formed  later  in  peritonitis.  It  is 
often  situated  more  laterally.  The  exudation  remains  fluid  longer. 
But  in  the  last  stage  it  may  be  impossible  to  distinguish  them.  A 
retroflexed  gravid  uterus  is  accompanied  by  signs  of  pregnancy,  a 
peculiar  elasticity  of  the  body  of  the  uterus,  softness  of  the  lower 
uterine  segment  and  the  cervix,  and  a  distinct  angle  between  the  two. 
Extra-uterine  pregnancy  is  accompanied  by  signs  of  pregnancy,  and 
is  rarely  developed  in  Douglas's  pouch.  As  we  have  seen  above,  the 
two  are  frequently  combined. 

Prognosis. — The  prognosis  is  much  better  than  in  cases  of  free 
hemorrhage.  Most  patients  recover  if  not  interfered  with,  but  the 
process  is  a  slow  one.  Absorption  takes  from  three  weeks  to  six 
months.  Some  succumb,  however.  The  rupture  into  the  peritoneal 
cavity  ends  speedily  in  death  from  shock  or  septic  peritonitis.  After 
rupture  through  the  rectum  suppuration  may  continue  and  slowly  ex- 
haust the  patient's  vitality. 

Treatment. — During  the  first  stage  the  indications  are  to  arrest 
hemorrhage,  combat  shock,  and  relieve  pain.  The  patient  should  be 
moved  as  little  as  possible ;  her  head  should  be  low ;  bottles  with  hot 
water  should  be  applied  to  the  extremities ;  morphine  should  be 
given  hypodermically,  and  brandy  by  the  mouth.  An  ice-bag  should 
be  placed  over  the  symphysis,  and  ice-water  injected  into  the  vagina 
and  rectum,  unless  the  vitality  is  low,  when  very  hot  water  is  to  be 
preferred. 

In  the  inflammatory  stage  ice-bags,  hot- water  injections,  and  opium 
are  indicated. 

In  the  third  stage  absorption  should  be  promoted  by  the  use  of 
Priessnitz's  compress  (p.  187),  ichthyol,  iodine  (internally  and  exter- 
nally), mercury  ointment  or  plaster,  and  the  galvanic  current,  with  a 
large  negative  pole  in  the  vagina  and  Engelmann's  electrode  (p.  '2.31) 
on  the  abdomen.  The  vagina  should  be  kept  clean  by  means  of  an- 
tiseptic injections,  in  order  to  avoid  possible  infection. 

In  fresh  cases  all  operative  interference  is  absolutely  contra-indi- 
cated. If  there  is  any  likelihood  of  a  fluid  collection  in  the  pelvis 


654      .  DISEASES  OF   WOMEN. 

being  a  hematocele,  the  doctor  should  abstain  even  from  a  puncture 
with  a  hypodermic  syringe.  Even  if  his  instrument  is  aseptic  and 
he  disinfects  the  vagina,  germs  of  suppuration  and  putrefaction  may 
enter  into  this  mass,  which  is  so  particularly  favorable  for  their  prop- 
agation, and  cost  the  patient  her  life. 

If,  on  the  other  hand,  softening  of  the  tumor,  with  high  tempera- 
ture, frequent  pulse,  dry  skin,  chills,  and  pain  in  loins  and  legs 
denote  that  suppuration  has  taken  place,  an  opening  should  be  made 
in  the  vagina  large  enough  to  introduce  one  or  two  fingers ;  the  sac 
should  be  emptied  and  washed  out  with  antiseptic  fluid,  and  a  finger- 
thick  T-shaped  soft-rubber  tube  introduced.  If  there  is  any  bleed- 
ing, the  cavity  is  packed  with  iodoform  gauze  for  forty-eight  hours 
before  using  the  tube.  The  end  of  the  tube  is  surrounded  with  iodo- 
form gauze  and  rubber  tissue,  and  the  vagina  packed  loosely  with 
gauze.  Once  or  twice  a  day  mild  antiseptic  injections  are  made 
through  the  tube  (thymol  is  particularly  appropriate  on  account  of  its 
blandness). 

The  incision  in  the  vagina  may  be  made  in  the  median  line,  where 
there  is  the  least  chance  of  wounding  vessels  and  the  accumulated 
blood  keeps  the  rectum  away;  but  of  late  most  operators  prefer 
a  transverse  incision  just  behind  the  cervix  (p.  484). 

If  the  blood-cyst  has  ruptured  into  the  rectum,  and  suppuration 
continues,  exhausting  the  patient,  it  is  best  to  make  a  counter-opening 
in  the  vagina  and  insert  a  drainage-tube.  The  sac  may  be  so  thick 
and  stiff  that  a  soft  tube  is  compressed.  Then  it  is  necessary  to  have 
one  of  hard  rubber  closed  with  a  stopcock. 

Another  indication  for  operation  is  a  very  slow  absorption.  If  the 
collection  is  large,  and  at  the  end  of  a  month  no  perceptible  diminu- 
tion has  taken  place,  the  patient  may  be  spared  the  annoyance  of 
spending  many  months  in  bed  by  evacuating  the  contents  of  the  sac. 
Operation  is  also  indicated  in  repeated  relapses.  As  in  such  a  case 
we  may  expect  some  bleeding,  the  sac  should  be  tightly  packed  with 
iodoform  gauze,  which  may  be  left  in  for  a  week. 

Vaginal  incision  is  much  safer  than  abdominal,  on  account  of  the 
danger  of  septic  peritonitis  in  the  latter.  But  if  the  extravasation 
cannot  be  reached  from  the  vagina,  laparotomy  is  indicated.  The  in- 
cision may  be  subperitoneal  or  transperifoneal.  For  the  former  an 
incision  is  made  above  and  parallel  to  Poupart's  ligament,  the  peri- 
toneum lifted  up,  and  an  incision  made  into  the  sac  without  opening 
the  peritoneal  cavity.  If  this  is  accidentally  opened,  the  opening 
should  be  enlarged  and  tamponed  with  iodoform  gauze  for  twenty- 
four  hours,  until  adhesions  have  formed.  Then  the  gauze  is  removed 
and  the  tumor  opened.  The  cavity  once  emptied,  a  counter-opening 
is  made  in  the  vaginal  vault  and  through-drainage  established. 

Transperitoneal  laparotomy  is  performed  in  the  median  line.     If 


DISEASES  OF  THE  PELVIS.  655 

possible,  the  sac  should  be  stitched  to  the  abdominal  wall,  and  drainage 
established  in  that  way ;  but  often  it  is  impossible  because  there  is  no 
separate  wall.  Then  we  can  only  wash  the  cavity  out  with  an  anti- 
septic solution,  and  drain  with  iodoform  gauze  through  the  wound  in 
the  abdominal  wall. 

C.  Hematoma. 

Pelvic  hematoma,  or  hematoma  of  the  broad  ligament,  is  an  effusion 
of  blood  in  the  pelvic  connective  tissue  above  the  levator  ani  muscle, 
most  frequently  between  the  layers  of  the  broad  ligament,  whence  it 
may  extend  under  the  pelvic  peritoneum,  up  under  the  abdominal 
peritoneum,  and  down  on  the  side  of  the  vagina.1 

Pathological  Anatomy. — The  blood  is  situated  in  the  loose  connec- 
tive tissue  between  the  two  layers  of  the  broad  ligament  and  between 
the  peritoneum  and  the  underlying  fascia.  In  most  cases  it  is  not  a 
very  large  collection,  but  the  sac  may  contain  several  pints  of  blood, 
and  form  a  tumor  that  nearly  mounts  to  the  umbilicus.  As  a  rule,  it 
is  unilateral,  but  both  sides  may  be  affected,  and  then  the  two  lateral 
tumors  are  united  by  an  isthmus  in  front  of  and  behind  the  uterus,  and 
the  rectum  is  narrowed  by  a  ring-shaped  stricture.  The  flow  is  arrested 
by  the  resistance  offered  by  the  surrounding  sac,  and  the  blood  does 
not  coagulate  so  rapidly  as  in  hematocele.  There  may  develop  some 
peritonitis,  but  less  than  in  hematocele.  The  sac  may  rupture,  with 
the  formation  of  a  secondary  hematocele,  or  it  may  suppurate,  so  as 
to  become  a  pelvic  abscess.  (See  Cellulitis.) 

Etiology. — Since  the  connective  tissue  of  the  pelvis  becomes  laxer 
by  pregnancy,  multiparous  and  pregnant  women,  as  well  as  puerperse, 
are  more  apt  to  be  affected.  A  varicocele  or  the  fetal  sac  in  tubal  preg- 
nancy may  rupture  in  such  a  place  that  the  blood  escapes  between  the 
layers  of  the  broad  ligament,  and  not  into  the  peritoneal  cavity.  Ex- 
cessive coition  may  be  the  exciting  cause.  The  accident  happens 
most  frequently  during  menorrhagia  or  the  pseudo-menstruation  fol- 
lowing oophorectomy  and  ovariotomy.  The  patient  may  be  in  perfect 
health. 

Symptoms. — Suddenly  the  patient  feels  pain  in  the  pelvis,  with 
faintness  and  rapid,  small  pulse,  but  the  attack  is  less  alarming  than 
in  hematocele. 

The  vagina,  and  even  the  skin,  may  have  a  bluish  color.  A 
doughy  tumor  is  felt  on  one  side  of  the  uterus,  which  it  pushes  over 
to  the  opposite  side  and  upward.  If  the  affection  is  bilateral,  the 
uterus  is  lifted  up.  The  tumor  is  in  close  connection  with  the  uterus, 

1  According  to  W.  A.  Freund  (Qynakologische  Klinik,  Strasburg.  1885,  vol.  i.  p. 
219)  the  pelvic  hematoma  may  in  non-puerperal  cases  form  between  the  rectum  and 
the  vagina,  and  in  puerperal  cases  extend  from  the  sides  of  the  vagina  to  the  ante- 
rior abdominal  wall,  the  kidneys,  and  into  the  mesentery,  without  entering  the  broad 
ligament. 


656  DISEASES  OF  WOMEN. 

which  is  rendered  immobile.  As  a  rule,  the  tumor  does  not  rise 
beyond  the  pelvic  brim,  but  it  may,  as  stated  above,  ascend  to  the 
neighborhood  of  the  umbilicus  and  be  distinctly  fluctuating. 

Diagnosis. — The  effusion  is  less  rapid,  causes  less  pain  and  shock, 
and  forms  a  distinct  tumor  sooner  than  in  hematocele.  In  large  bilat- 
eral collections  in  the  connective  tissue  the  upper  surface  is  convex, 
the  lower  more  or  less  irregularly  concave,  so  that  the  whole  reminds 
one  of  a  jellyfish,  while  hematocele  bulges  into  the  vagina  with  a  con- 
vex end  like  a  dilated  bag.  The  ring-shaped  stricture  of  the  rectum 
is  characteristic.  The  tumor  is  found  just  within  the  vulva,  while  in 
most  cases  of  hematocele  its  base  is  situated  higher  up.  It  is  found 
on  one  or  both  sides  of  the  vagina — in  hematocele,  behind.  It  re- 
mains longer  fluid.  The  uterus  is  sooner  rendered  immobile.  Fever 
sets  in  later.  In  ceUutitis  the  fever  precedes  the  formation  of  the 
tumor,  the  uterus  is  not  immobilized  so  soon,  and  the  inflammation 
is  referable  to  childbirth,  abortion,  or  operative  interference. 

Prognosis. — Nearly  all  patients  recover  in  from  ten  to  fourteen 
days.  Only  when  occurring  in  pregnancy,  childbirth,  or  the  puer- 
perium  is  it  dangerous.  As  a  rule,  the  blood,  and  even  the  fetus  in 
extra-uterine  pregnancy,  is  absorbed.  Suppuration  is  rare.  But  the 
sac  may  rupture  into  the  peritoneal  cavity,  and  in  extra-uterine  preg- 
nancy the  fetus  may  continue  to  grow. 

Treatment. — As  a  rule,  no  operation  should  be  performed,  but  the 
same  measures  be  adopted  as  for  hematocele.  If  the  bleeding  is 
severe  or  the  tumor  very  large,  and  does  not  become  absorbed  or  is 
changed  into  an  abscess,  one  of  the  operations  described  under  Hema- 
tocele should  be  performed. 

In  laparotomy  the  sac,  if  possible,  should  be  stitched  to  the  abdom- 
inal incision,  but  it  may  be  so  brittle  that  it  cannot  be  lifted  so  far 
even  when  pressure  is  made  against  the  vaginal  roof.  In  such  cases 
the  uterus  may  sometimes  be  used  to  fill  the  gap.  A  suture  is  carried 
through  the  abdominal  wall,  the  edge  of  the  sac,  the  peritoneal  cover 
of  the  uterus,  the  other  edge  of  the  sac,  and  the  other  side  of  the 
abdominal  wall.  If  it  appears  desirable,  a  second  suture  may  be 
inserted  in  a  similar  way.  When  these  sutures  are  drawn  taut,  the 
sac  is  closed  by  the  uterus,  and  the  latter  brought  in  contact  with  the 
abdominal  wall.1 

Galvanopuncture  through  the  vagina,  with  a  fine  platinum-pointed 
needle  connected  with  the  positive  pole,  and  with  a  current  of  50 
milliamp£res,  used  from  five  to  ten  minutes,  has  been  recommended. 
In  a  small  hematoma  one  application  suffices ;  in  larger  it  may  be 
repeated  in  from  three  to  six  days.2 

1  Marcus  Rosenwasser  of  Cleveland,  O.,  Annals  of  Gynecoloyy,  March,  1891,  vol. 
iv.  p.  325. 

2  A.  H.  Goelet,  N.  Y.  Med.  Record,  March  8,  1890,  vol.  xxrvii.  p.  279. 


DISEASES  OF  THE  PELVIS.  657 

CHAPTER  VII. 
PERIMETRIC  INFLAMMATION. 

BY  "  perimetric  inflammation  "  is  understood  the  inflammation  of 
the  pelvic  peritoneum,  the  pelvic  connective  tissue,  the  veins,  and  the 
lymphatic  vessels  and  glands  in  the  pelvis.  On  account  of  the  inti- 
mate connection  between  these  different  structures  and  with  the 
neighboring  organs,  it  is  quite  common  that  more  than  one  of 
them  is  affected  at  a  time,  and  it  is  evident  that  there  must  be  a  cer- 
tain similarity  between  all  pelvic  inflammations;  but  according  to 
the  tissue  from  which  the  inflammation  starts  or  the  one  that  is  most 
affected  we  distinguish  perimetric  inflammations  by  different  names, 
and  these  different  diseases  present  also  sometimes  peculiarities  as  to 
frequency,  physical  signs,  prognosis,  and  indications  for  treatment. 
Our  old  knowledge,  based  only  on  clinical  observations  and  post-mor- 
tem examinations,  has  been  greatly  extended  and  corrected  by  the 
numerous  laparotomies  that  have  been  performed  of  late  years  in  these 
conditions.  Thus  we  describe  separately  pelvic  peritonitis,  pelvic  cellu- 
litis,  pelvic  lymphangitis,  and  pelvic  phlebitis. 

A.  Pelvic  Peritonitis. 

Pelvic  peritonitis  is  the  inflammation  of  that  part  of  the  peritoneum 
which  covers  more  or  less  of  the  uterus,  the  tubes,  the  bladder,  the 
rectum,  the  vagina,  and  the  walls  of  the  pelvis,  and  which  forms  the 
broad  ligaments. 

Pelvic  peritonitis  is  sometimes  called  perimetritis  as  a  companion 
name  to  parametritis,  which  is  used  to  designate  inflammation  of  the 
connective  tissue ;  but  since  these  names  are  not  very  characteristic  in 
regard  to  their  derivation, — -peri  meaning  "  around,"  and  para,  "  at 
the  side  of," — since  their  sound,  especially  in  English,  is  so  much  alike 
that  there  is  little  for  the  memory  to  take  hold  of,  and  since  most 
excellent  treatises  have  been  written  about  them  under  their  old 
names,  we  take  it  to  be  more  practical  to  preserve  the  words  "  peri- 
tonitis" and  "  cellulitis,"  although  the  latter  leaves  much  to  be  desired 
from  an  etymological  standpoint,  being  a  combination  of  a  Latin  root 
and  a  Greek  suffix,  and  the  root  itself  being  a  remnant  from  the  time 
when  what  we  now  call  connective  tissue  was  designated  as  cellular 
tissue. 

Of  all  the  perimetric  inflammations,  peritonitis  is  by  far  the  most 
common. 

Pathological  Anatomy. — Different  forms  of  pelvic  peritonitis  have 
been  distinguished — namely,  the  serous,  the  adhesive,  and  the  suppn- 
rative — which  are  sometimes  only  different  stages  of  the  same  disease. 
The  inflammation  may  be  acute  or  chronic. 

42 


658  DISEASES  OF  WOMEN. 

In  nearly  all  these  cases  are  found  diseased  tubes,  and  usually  the 
ovary  is  implicated.  Often  the  inflammation  of  the  tubes  can  be 
traced  back  to  the  corresponding  condition  in  the  uterus.  First  the 
peritoneum  becomes  injected,  its  endothelium  is  lost,  and  serum  is 
secreted  from  the  denuded  surface.  The  neighboring  organs  are 
agglutinated  by  a  yellow  tibrinous  mass  that  becomes  organized,  and 
forms  a  false  membrane  which  encapsulates  the  serous  exudation. 
Serum  may  also  be  enclosed  in  the  meshes  of  the  adjacent  connective 
tissue,  forming  an  inflammatory  edema.  The  serum  may  gravitate 
down  into  Douglas's  pouch  or  be  found  in  one  of  the  para-uterine 
fossae,  or  the  quantity  may  be  large  enough  to  fill  the  whole  pelvis, 
and  even  surmount  the  iliopectineal  line.  As  a  rule,  the  fluid  is 
found  behind  the  uterus  and  pushes  it  forward,  sometimes  also  to 
one  side,  but  in  exceptional  cases  the  uterus  being  already  bound 
down  with  adhesions,  the  fluid  is  found  above  and  in  front  of  it. 

Later  this  serum  in  the  peritoneal  cavity  becomes  inspissated,  form- 
ing a  yellow  mass  like  orange-jelly,1  the  more  watery  part  being 
reabsorbed  and  connective  tissue  being  formed.  Finally,  the  whole 
may  be  absorbed,  or,  as  it  is  called,  the  disease  ends  in  resolution. 

Even  solid  adhesions  can  probably  disappear  without  leaving  any 
trace ;  at  least  a  uterus  that  at  one  time  is  immovably  moored  to  the 
surroundings  may  regain  entire  mobility.  This  absorption  is  doubt- 
less favored  by  the  constant  movement  in  which  the  pelvic  organs  are 
kept  by  respiration,  the  different  degrees  of  fullness  of  the  bladder 
and  intestine,  their  evacuation,  sneezing,  coughing,  muscular  exer- 
tion, and  sometimes  an  intervening  pregnancy  in  which  the  adhesions 
are  softened  and  stretched.  But,  as  a  rule,  adhesions  remain  indef- 
initely. The  serous  cyst  may  remain  unchanged  for  many  months. 
Sometimes  the  contents  become  bloody  in  consequence  of  rupture  of 
vessels  in  the  adhesions,  and  in  rare  cases  they  become  purulent.  In 
the  adhesive  form  we  find  on  one  or  both  sides  of  the  uterus  a  tumor 
composed  of  the  tube,  the  ovary,  and,  perhaps,  a  knuckle  of  intestine  or 
a  part  of  the  omentum,  all  matted  together  with  plastic  lymph  or 
organized  adhesions.  As  a  rule,  this  mass  is  bound  in  the  same  way 
to  the  posterior  surface  of  the  broad  ligament,  or,  more  rarely,  to  the 
posterior  surface  of  the  uterus,  the  anterior  surface  of  the  rectum, 
the  superior  surface  of  the  bladder,  or  the  pelvic  wall.  Serum  may  ex- 
tra vasate  into  such  a  mass.  The  ovary  is  covered  with  a  false  membrane. 
The  tube  is  contorted,  and  its  sinuosities  bound  together ;  the  abdominal 
ostium  is  often  closed ;  the  fimbriae  may  have  grown  together ;  bands 
of  adhesions  form  constrictions  which  cause  adhesive  salpingitis  and 
strictures  or  total  partitions  in  the  interior  of  the  tube.  The  uterus  may 
be  retroflexed  or  retroverted,  and  bound  to  the  rectum,  or,  more  rarely, 
anteflexed  or  anteverted,  and  bound  to  the  bladder.  The  condition 
1  John  Williams,  Obst.  Trans,  of  I<ondon,  June  3,  1885,  vol.  xxvii. 


DISEASES  OF  THE  PELVIS.  659 

we  here  describe,  as  it  presents  itself  in  laparotomies,  is  in  most  cases 
probably  a  late  stage  of  the  preceding  form,  but  in  some  cases  there  is 
little  serous  effusion  from  the  beginning,  and  the  exuded  fibrinous 
lymph  is  soon  transformed  into  connective  tissue  by  a  process  similar 
to  that  causing  dry  pleurisy.  This  dry  chronic  form  is  particularly 
frequent  in  connection  with  tuberculosis,  while  the  common  acute  form 
is  ordinarily  accompanied  by  more  or  less  serous  exudation. 

Pelvic  peritonitis  may  be  suppurative  from  the  beginning,  as 
when  gonorrhea  extends  through  the  uterus  and  tubes,  or  a  serous 
exudate  may  in  the  course  of  time,  instead  of  being  absorbed,  become 
purulent.  Fortunately,  this  is  a  comparatively  rare  occurrence. 

Pus  in  the  pelvis  may  be  found  in  the  tube  (pyosalpinx),  in  the 
ovary  (ovarian  abscess),  in  the  peritoneal  cavity,  or  in  the  subperito- 
neal  connective  tissue.  Often  it  is  found  in  all  these  localities  at  the 
same  time.  We  have  described  the  first  two  in  dealing  with  the 
Diseases  of  the  Tube  and  the  Ovary.  Here  we  will  only  add  that 
the  pus-filled  tube  may  become  so  distended  that  it  occupies  the 
whole  pelvis,  where  it  may  adhere,  so  that  it  cannot  be  separated  from 
the  peritoneum.  The  pelvic  abscess  of  the  connective  tissue  will  be 
described  below.  Here  we  have  only  to  do  with  the  intraperitoneal 
collection  of  pus.  On  account  of  the  preexisting  wall  formed  by 
adhesions  and  the  new  irritation  caused  by  the  acrid  contents,  this 
abscess,  although  situate  in  the  peritoneal  cavity,  is  in  reality,  as  a 
rule,  separated  from  it  by  a  complete  partition  of  varying  thickness. 
This  intraperitoneal  abscess  may  open  into  a  hollow  organ,  most  fre- 
quently the  rectum,  less  often  the  vagina,  and  rarely  the  bladder.  It 
may  rupture  into  the  peritoneal  cavity,  which,  fortunately,  is  a  rare 
occurrence,  and  it  may  find  its  way  out  through  the  peritoneum,  the 
connective  tissue,  and  the  skin  above  or  below  Poupart's  ligament,  or 
burst  in  the  gluteal  region,  which  it  reaches  through  the  great  sacro- 
sciatic  foramen.1 

Often  the  abscess  is  only  partially  emptied  through  a  long,  narrow, 
and  devious  canal  surrounded  by  indurated  tissue,  or  refills  again 
when  the  outlet  becomes  blocked  up.  Such  fistulous  abscesses  may 
remain  indefinitely  as  a  source  of  fresh  attacks  of  peritonitis  or  as  a 
drain  on  the  patient's  constitution,  which  makes  her  an  invalid  or 
causes  death  by  exhaustion. 

In  contact  with  the  purulent  collection  the  muscular  fibers  of  the 
uterus  are  apt  to  undergo  fatty  degeneration.  The  inflammation  may 
follow  the  lymphatics  through  the  infundibulopelvic  ligament  up  to 

1  W.  M.  Polk  thinks  this  is  brought  about  by  agglutination  of  the  fimbriated  end 
of  the  tube  to  some  point  of  the  peritoneum,  which  yields  and  allows  the  migration 
of  the  pus  ("  Peri-uterine  Inflammation,"  N.  Y.  Med.  Record,  Sept.  18,  1886,  vol. 
xxx.  p.  315). 


660  DISEASES  OF   WOMEN. 

the  diaphragm,  and  cause  diaphragmatic  pleuritis ;  but  this  is  of  the 
dry  variety  and  of  minor  importance. 

Microscopical  investigations1  have  shown  that  in  peritonitis  the  en- 
dothelia  of  the  peritoneum  and  blood-vessels,  the  epithelium  of  the 
ovary,  the  fibrous  connective-tissue  bundles,  and  the  smooth  muscle- 
fibers  all  break  up,  forming  inflammatory  corpuscles — i.  e.  small  round 
cells — which,  if  they  continue  in  connection  with  one  another,  become 
spindle-shaped  and  form  new  connective  tissue  (adhesive  peritonitis), 
or,  if  the  connection  between  them  is  interrupted,  form  pus-corpuscles 
(suppurative  peritonitis).  The  latter  is  due  to  the  influence  of  gono- 
cocci,  staphylococci,  or  streptococci.  The  most  common  cause  is 
gonococci.  The  other  microbes  may  be  introduced  by  unclean  fingers 
and  instruments,  or  may  be  due  to  rupture  of  vessels  in  injuries,  since 
they  circulate  in  the  blood,  or  may  be  derived  from  a  suppurating 
surface  in  a  remote  part  of  the  body. 

False  membranes  consist  of  connective  tissue  with  interspersed 
cells  and  blood-vessels,  and  contain  sometimes  miliary  abscesses. 

According  to  the  bacteriologists,2  gonococci  do  not  affect  the  lym- 
phatics, but  travel  along  the  mucous  membrane  of  the  uterus  and  the 
tubes,  while  staphylococci  are  carried  more  rapidly  by  the  lymphatics 
than  in  following  the  mucous  membrane,  and  do  not  invade  the  veins 
until  the  lymph-vessels  are  choked.  Streptococci  are  only  found  ex- 
tensively in  puerperal  cases,  and  are  transmitted  in  the  same  manner 
as  the  staphylococci. 

Etiology. — Pelvic  peritonitis  may  develop  in  the  fetus.  In  adults 
it  is  in  most  cases  added  to  preexisting  disease  of  some  pelvic  organ, 
especially  salpingitis.  A  serous  peritonitis  may  accompany  purulent 
salpingitis,  for  which  an  explanation  may  be  sought  by  supposing  the 
adhesions  to  serve  as  a  filter,  retaining  the  pyogenic  microbes.  Me- 
tritis  may  spread  from  the  endometrium  through  the  muscular  wall 
out  to  the  peritoneum,  or  it  may  first  reach  the  connective  tissue,  the 
lymphatics,  or  veins  of  the  broad  ligament,  and  secondarily  the  peri- 
toneum. Enlargement,  displacement,  fibroids,  and  cancer  of  the 
uterus  are  all  very  apt  to  be  accompanied  by  peritonitis.  Hematocele 
is  limited  by  adhesive  inflammation.  Peritonitis  may  be  due  to  rup- 
ture of  a  tubal  pregnancy  or  an  ovarian  hematoma  or  abscess. 

Tubercular  peritonitis  is  usually  propagated  from  the  same  affection 
in  the  tube.  It  is  commonly  preceded  by  simple  peritonitis. 

Peritonitis  is  chiefly  the  result  of  gonorrhea,  trauma,  childbirth,  or 
disturbance  of  the  menstrual  flow,  in  all  or  most  of  which  cases  the 
real  morbific  cause  is  infection  with  microbes. 

Traumatic  peritonitis  is  often  brought  about  by  gynecological  treat- 
ment, such  as  the  passing  of  the  uterine  sound,  application  of  caustics, 

1  Dr.  M.  Dixon  Jones,  Medical  Record,  May  28,  1892,  vol.  xli.  p.  599. 

2  W.  R.  Pryor,  Amer.  Jour.  Obst.,  May,  1891,  vol.  xxv.  p.  603. 


DISEASES  OF  THE  PELVIS.  661 

curetting,  intra-uterine  injections,  tents,  stem-pessaries,1  incision 
of  the  cervix,  or  trachelorrhaphy. 

Puerperal  peritonitis  may  be  gonorrheal  or  traumatic,  in  the  latter 
case  beginning  as  a  hematoma  or  being  due  to  microbes  deposited  on 
wounds  by  unclean  lingers  or  instruments  and  similar  carriers  of 
infection. 

Menstrual  peritonitis  may  be  due  to  a  malformation  of  the  tubes 
or  to  flexion  or  stenosis  of  the  uterine  canal,  but  is  in  most  cases  brought 
on  by  exposure  to  cold  or  by  coition.  It  is  not  rare  in  washerwomen 
who  get  wet  feet,  or  prostitutes  who  bathe  the  genitals  with  cold 
water  in  order  to  stop  the  inconvenient  flow. 

Perhaps  also  masturbation  may  cause  peritonitis. 

Symptoms. — The  symptoms  of  an  acute  attack  of  pelvic  peritonitis 
are  much  like  those  of  acute  inflammation  of  the  pelvic  organs.  The 
patient  experiences  a  sudden  severe  pain  in  one  side  of  the  pelvis, 
which  may  extend  over  to  the  opposite  side  or  down  the  anterior  sur- 
face of  the  thigh.  She  feels  faint  and  sometimes  nauseated,  and  may 
vomit.  As  a  rule,  she  has  a  chill,  followed  by  rise  in  temperature, 
and  a  frequent  small  pulse.  Very  commonly  she  complains  of  rectal 
and  vesical  tenesmus.  Her  face  has  an  expression  of  anxiety,  and 
she  may  become  delirious.  The  abdomen  is  distended  and  tender. 
Metrorrhagia  is  of  frequent  occurrence.  On  vaginal  examination  is 
found  an  exquisitely  tender  swelling  occupying  Douglas's  pouch  or 
situated  to  one  side  of  the  uterus,  and  pushing  the  latter  up  against 
the  symphysis,  and  sometimes  over  to  the  opposite  side,  but  at  the 
same  time  canting  the  edge  forward.  It  is  immovable.  Sometimes 
crepitation  is  heard  and  felt,  but  the  swelling  is  too  tense  to  give 
fluctuation. 

As  a  rule,  the  fluid  is  absorbed,  the  tumor  becomes  smaller  and 
disappears,  and  the  uterus  may  regain  its  normal  mobility.  In  other 
cases  induration  and  adhesions  remain,  and  the  uterus  continues  more 
or  less  immobile.  In  other  cases,  again,  recurring  fever,  chills,  night- 
sweats,  and  a  yellowish  hue  of  the  skin  indicate  the  formation  of  pus ; 
but  all  these  symptoms  may  be  absent  and,  nevertheless,  the  exudate 
become  purulent.  Sometimes  the  transformation  is  marked  by  an 
extension  of  the  inflammation  up  into  the  abdomen,  by  the  occurrence 
of  persistent  diarrhea  due  to  ulcerative  enteritis,  or  by  bronchopneu- 
monia  with  mucopurulent  expectoration. 

While  the  above  description  applies  to  most  cases  of  acute  pelvic- 
peritonitis,  there  are  others  that  present  some  peculiarities.  Thus 
the  temperature  may  be  normal,  or  even  subnormal,  or  fluctuate  be- 
tween a  high  and  a  low  mark ;  which  are  bad  signs.  Pain  and  tumor 
may  be  absent  in  particularly  dangerous  cases.  The  tumor  may  fill 

1  I  have  described  a  case  of  this  last  kind  in  Amer.  Jour.  Obst.,  1870,  vol.  xii. 
p.  756. 


662  DISEASES  OF  WOMEN. 

the  whole  pelvis,  extend  considerably  above  the  brim,  or  be  as  small 
as  a  pigeon's  egg.  It  may  change  in  position  and  size  on  account  of 
the  presence  or  disappearance  of  the  accompanying  edema  or  con- 
gestion. 

The  chronic  form  may  be  really  chronic  from  the  beginning,  but 
oftener  it  is  a  succession  of  acute  attacks  brought  on  by  bodily  exertion, 
trickling  of  tube-contents  into  the  peritoneal  cavity,  rupture  of  a  fol- 
licular  cyst  or  a  distended  tube.  In  this  form  the  patient  is  often 
able  to  be  up  and  about,  and  even  to  do  some  work,  but  she  has  more 
or  less  constant  pain,  with  menstrual  exacerbations.  Menorrhagia  or 
amenorrhea  is  common.  By  bimanual  examination  we  feel  on  the 
side  of  the  uterus  the  tumor  described  above  in  speaking  of  the 
pathological  anatomy,  or  a  large  tumor  that  mounts  into  the  abdomen 
simulating  an  ovarian  cyst.  Sometimes  a  fibrinous  discharge  from 
the  uterus  accompanies  a  serous  collection  in  the  pelvis. 

Prostitutes  suffer  often  from  a  condition  called  colica  scortorum. 
Its  symptoms  are  pelvic  pain,  fever,  and  purulent  discharge,  and  it 
is  due  to  slight  attacks  of  peritonitis,  and  probably  to  painful  con- 
tractions of  the  inflamed  tubes. 

Diagnosis. — It  may  be  impossible  to  differentiate  pelvic  peritonitis 
from  other  conditions,  but  in  most  cases  the  diagnosis  is  easy.  In 
fresh  cases  the  bulging  tumor  filling  Douglas's  pouch  and  pressing 
the  uterus  up  against  the  symphysis  is  characteristic.  Hematocele 
occupies,  however,  the  same  position,  but  it  begins  more  suddenly  and 
with  greater  violence,  and  the  tumor  is  at  first  fluid,  and  becomes 
harder  (p.  650),  whereas  peritonitis  takes  an  opposite  course.  Hemor- 
rhage may  take  place  into  a  serous  pseudocyst,  but  the  red  blood- 
corpuscles  are  then  changed  into  pale  spherical  bodies,  while  in  hema- 
tocele  the  fluid  is  pure  blood  with  well-preserved  or  shrunken  blood- 
corpuscles.  In  cettulitis  the  symptoms  are  less  severe,  the  tumor  is 
situated  close  up  to  the  side  of  the  uterus,  and  pushes  it,  together 
with  the  cervix,  over  to  the  other  side.  It  may  form  two  tumors, 
one  on  either  side,  connected  by  a  bridge  in  front  and  behind  the  cer- 
vix. In  peritonitis  the  whole  vaginal  vault  presents  one  smooth, 
hard  mass.  The  immobility  of  the  uterus  is  less  pronounced  than 
in  peritonitis.  If  cellulitis  extends  above  the  brim,  it  always  follows 
the  bone  closely,  while  the  peritonitic  tumor,  as  a  rule,  is  situated  far- 
ther in,  and  allows  us  to  insert  the  fingers  between  it  and  the  bony  pel- 
vis. If  cellulitis  involves  the  psoas  and  iliacus  muscles,  relief  is  found 
by  flexing  the  corresponding  limb ;  in  peritonitis  both  limbs  must  be 
drawn  up  to  obtain  the  same  effect.  In  chronic  oophontis  the  ovary 
may  be  movable,  its  shape  is  more  or  less  recognizable,  and  it  shows 
an  unusual  tenderness.  In  salpingitis  the  tumor  is  sausage-shaped, 
often  bilateral,  and  follows  the  edge  of  the  uterus.  In  cases  of  long 
standing  the  tube,  may,  however,  be  so  distended  as  to  fill  the  pelvis, 


DISEASES  OF  THE  PELVIS.  663 

and  adapt  itself  to  the  peritoneum,  and  then  the  diagnosis  between 
this  condition  and  a  collection  situated  directly  in  the  peritoneal  cav- 
ity becomes  impossible.  In  extra-uterine  pregnancy  there  are  signs  of 
pregnancy,  and  the  tumor  is  situated  laterally.  In  cases  of  fibroid  or 
fibrocystic  tumors  of  the  uterus  this  is,  as  a  rule,  movable,  and  the 
tumor  moves  with  it.  Fibroids  are  felt  as  solid  nodular  masses,  and 
there  is  no  history  of  acute  inflammation.  The  uterine  cavity  is,  as 
a  rule,  enlarged.  In  oophoralgia  there  is  neither  tumor  nor  inflamma- 
tion. An  old  encysted  serous  collection  is  easily  mistaken  for  an 
immovable  ovarian  cyst,  but  there  is  the  history  of  the  acute  begin- 
ning, and  exploratory  puncture  shows  a  citrine  fluid  containing  leuco- 
cytes and  forming  a  small  coagulum  by  exposure  to  the  air.  In  the 
same  way  a  peritonitic  cyst  is  distinguished  from  a  cyst  of  the  broad 
ligament  or  a  hydatid.  In  tubercular  peritonitis  the  lungs  are,  as  a 
rule,  affected. 

Prognosis. — When  the  disease  is  of  traumatic  or  menstrual  origin 
the  prognosis  is  good,  both  as  to  life  and  complete  recovery,  but 
absorption  may  be  very  slow.  The  gonorrheal  form  is  much  more 
dangerous,  and  may  in  short  time  lead  to  death  by  general  peritonitis 
or  give  rise  to  chronic  peritonitis,  which  may  end  fatally  through 
exhaustion,  embolus,  or  tuberculization.  The  puerperal  form  is 
very  grave. 

Often  the  patient  is  left  with  impaired  health.  Uterine  displace- 
ments are  a  common  sequel.  Hematocele  may  develop  in  the  adhe- 
sions (p.  651).  Intestinal  adhesions  may  cause  constipation,  alternat- 
ing with  dianrhea,  or  occlusion  of  the  bowel.  Pressure  on  the  nerves 
of  the  pelvis  may  cause  sciatica  or  reflex  paralysis.  Sterility  is  very 
common,  the  ovary  being  covered  with  a  false  membrane  that  prevents 
the  ovum  from  escaping,  or  the  tubes  being  sealed  by  adhesions.  If 
impregnation  takes  place,  there  is  danger  of  the  ovum  being  arrested 
in  the  tube,  or  if  it  reaches  the  uterus,  the  presence  of  a  layer  of  old, 
unyielding  false  membrane  around  this  organ  or  its  fixation  by 
adhesions  in  an  untoward  position  may.  lead  to  abortion. 

Treatment. — In  regard  to  prophylaxis  the  reader  is  referred  to 
what  has  been  said  in  speaking  of  Salpingitis  (p.  531).  The  patient 
must  lie  quietly  in  bed,  and  be  kept  on  fluid  diet  (p.  224).  Often  a 
pillow  rolled  up,  tied,  and  placed  under  her  knees  is  grateful  to  her. 
In  the  acute  stage  an  ice-bag  or  ice-water  coil  should  be  applied  over 
the  uterus,  or,  if  cold  is  not  well  borne,  a  hot  poultice  or  stupe  (p.  1S7) 
may  be  substituted.  Frequent  hot  vaginal  injections  should  be  ordered, 
to  which  in  infectious  cases  antiseptics  should  be  added  (p.  172). 
Heat  may  be  used  continually  by  combining  the  poultice  on  the 
abdomen  with  one  in  the  vagina,  or  placing  a  colpeurynter  with  hot 
water  in  the  latter.  Pain  should  be  subdued  by  opiates.  If  it  is 
severe,  it  is  charitable  to  begin  with  a  hypodermic  injection  of  £  to 


664  DISEASES  OF  WOMEN. 

£  of  a  grain  of  morphine.  Later,  the  drug  is  given  by  the  mouth  in 
doses  of  ^  of  a  grain,  repeated  often  enough  to  keep  the  patient  com- 
fortable, for  which  purpose  iu  most  cases  not  much  is  required,1  or 
suppositories  with  J  grain  of  pulvis  opii  are  administered  by  the  rec- 
tum every  two  or  three  hours. 

I  prescribe  in  this  as  in  all  inflammations  5  grains  of  quinine  every 
four  hours,  not  as  an  antipyretic,  but  as  an  antiphlogistic.  If  the 
temperature  rises  above  102°  Fahr.,  antipyretics  (p.  228)  are  indi- 
cated. Bacteriological  researches  having  shown  that  bacilli  find  their 
way  from  the  intestine,  and  change  a  comparatively  harmless  simple 
peritonitis  into  a  dangerous  septic  one,  it  is  a  wise  precaution  to  keep 
the  bowels  open  from  the  beginning  with  enemas  (p.  174)  or  aperients, 
preferably  sulphate  of  sodium  (a  heaping  teaspoonful,  repeated,  if 
necessary,  every  three  hours),  or,  if  salts  cause  vomiting,  calomel 
(gr.  j  every  hour  until  the  bowels  move). 

When  the  disease  after  eight  or  ten  days  enters  on  a  more  subacute 
stage, — that  is  to  say,  when  spontaneous  pain  and  fever  have  ceased 
and  the  tenderness  is  diminished, — the  patient  is  allowed  more  sub- 
stantial food,  and  Priessnitz's  compress  (p.  187)  should  replace  the 
ice.  A  few  days  or  a  week  later  the  abdomen  should  be  painted  with 
tincture  of  iodine,  followed  by  a  glycerin  compress  (p.  188).  When 
the  tenderness  has  abated  sufficiently  to  warrant  the  introduction  of  a 
speculum,  the  iodine  is  applied  with  greater  effect  to  the  vaginal  roof 
every  three  days  (p.  170),  and  combined  with  pledgets  with  ichthyol- 
glycerin  (p.  178),  abdominal  inunction  with  ichthyol  ointment  (10 
per  cent.),  and  the  internal  use  of  iodide  of  potassium.  ..By  this  time 
— about  three  weeks  since  she  was  taken  sick — the  patient  will,  as  a 
rule,  be  well  enough  to  get  up  cautiously  and  spend  most  of  the  day 
on  a  lounge.  Still  later,  when  she  is  well  enough  to  be  on  her  feet, 
galvanism  with  the  negative  pole  in  the  uterus  or  vagina  (p.  232). 
faradization  with  the  high  tension  secondary  current  for  ten  minutes 
every  day  (p.  230),  massage  (p.  190),  warm  entire  baths,  sitz-baths 
(p.  187),  and  the  constant  use  of  a  wet  abdominal  bandage  well  covered 
with  water-proof  material,  are  valuable  means  of  causing  absorption 
of  exudation  and  inflammatory  tissue.  Finally,  the  treatment  in 
places  where  they  have  mineral  mud,  so-called  "  moor,"  such  as  Fran- 
zensbad  or  Marienbad  in  Germany,  and  Sandefjord  in  Norway,  may 
be  recommended. 

If  serous  pseudocysts  remain  after  the  acute  symptoms  have  sub- 
sided, and  do  not  yield  readily  to  the  absorbent  treatment  described, 
much  time  may  be  saved  by  aspirating  the  fluid  (p.  159)  from  the 

1  In  this  respect,  as  in  many  others,  pelvic  peritonitis  differs  from  general  peri- 
tonitis, in  which  often  enormous  doses  are  not  only  well  borne,  but  beneficent.  (See 
Garrigues,  "  The  Opium  Plan  in  Puerperal  Peritonitis,"  N.  Y.  Med.  Jour.,  Jan.  24, 
1885,  vol.  xli.  p.  98.) 


DISEASES   OF  THE, PELVIS.  665 

vagina;  but  the  utmost  care  should  be  taken  in  disinfecting  both 
aspirator  and  vagina,  as  otherwise  the  inoffensive  serum  may  be  fol- 
lowed by  pus;  and  bladder,  ureters,  and  blood-vessels  must  be  care- 
fully avoided,  which  limits  the  safe  field  to  the  posterior  part  of  the 
pelvis  and  a  moderate  distance,  say  an  inch,  from  the  median  line. 

In  the  chronic  form  of  peritonitis,  or  when  the  acute  and  subacute 
stages  have  passed,  the  patient  is  allowed  moderate  exercise ;  her  diet 
should  be  nutritious  and  mildly  stimulating  (p.  224) ;  but  sexual 
intercourse  should  be  avoided  or  restricted  within  narrow  limits. 

To  the  therapeutic  measures  already  mentioned  may  be  added  pack- 
ing of  the  vagina  (p.  178),  which  may  help  to  stretch  adhesions  and 
further  their  absorption.  The  internal  use  of  resolvents  (p.  226)  has- 
tens absorption,  and  an  abdominal  belt  (p.  190)  often  gives  comfort 
by  removing  pressure  from  the  inflamed  peritoneum. 

Pelvic  Abscess.1 — If  the  fluid  in  the  sac  formed  by  the  perito- 
neum, pelvic  organs,  and  false  membranes  is  purulent,  it  should  be 
evacuated ;  and  the  question  arises,  from  what  side  is  it  best  to  attack 
the  sac — from  the  rectum,  the  vagina,  or  the  abdominal  wall?  To 
make  an  opening  in  the  rectum,  be  it  with  trocar,  aspirator,  or  knife,  is 
not  advisable,  as  the  abscess  inevitably  becomes  infected  with  the  con- 
tents of  the  bowels.  If  there  already  is  a  communication  with  the  rec- 
tum, opinions  about  the  best  way  of  treating  the  abscess  differ.  Some 2 
anesthetize  the  patient,  dilate  the  sphincter  ani  muscle  to  over-disten- 
tion,  tear  the  opening  in  the  rectum  down  to  the  bottom  of  the  abscess, 
scoop  out  with  finger  or  curette  all  granulations  and  old  bands,  wash 
out  the  cavity,  and  treat  it  exclusively  through  the  anus  till  it  is 
healed,  which  often  necessitates  a  repetition  of  the  operation  and  the 
use  of  sponge  tents  to  keep  open  the  entrance  to  the  abscess.  Most 
operators  prefer  to  introduce  a  sound  through  the  opening  in  the  rec- 
tum, bend  it  well  down  against  the  vaginal  roof,  and  make  a  counter- 
incision  there,  through  which  a  drainage-tube  may  be  drawn,  and  left 
until  the  cavity  is  closed.  It  is,  of  course,  kept  clean  with  daily  injec- 
tions of  antiseptic  fluid.  More  rarely  the  counter-opening  is  made 
in  the  abdominal  wall. 

If  the  purulent  collection  is  near  the  vaginal  roof,  and  does  not 
contain  over  two  ounces  of  pus,  some  advise  to  aspirate.  Others  use 
a  trocar  and  canula.  But  it  is  better  to  make  a  large  opening,  so  as 
to  be  sure  to  have  a  free  outlet  and  be  able  to  insert  a  drainage-tube. 
Some  make  this  opening  by  plunging  a  pointed  curved  pair  of  scissors, 

1  The  term  ."pelvic  abscess"   is  taken  in  different  senses  by  different  authors. 
Some  use  it  for  a  collection  of  pus  anywhere  in  the  pelvis ;  others  restrict  it  to  col- 
lections the  sac  of  which  cannot  be  removed  (Pozzi) ;  and  others,  again,  use  it  only 
to  designate  the  suppuration  of  the  connective  tissue  of  the  pelvis  (Thornas-Munde'). 
1  use  it  for  intra-  or  extra-peritoneal  purulent  collections  in  the  pelvis,  except  those 
situated  in  the  tube  or  the  ovary. 

2  H.  T.  Byford,  A  Case  of  Pdvic  Abscess,  Chicago,  1886. 


666  DISEASES  OF  WOMEN. 

through  the  posterior  vault  of  the  vagina  into  the  abscess  and  with- 
drawing them  open.  Then  they  enlarge  the  opening  with  an  expanding 
dilator,  clean  out  the  cavity  with  finger  and  curette,  removing  granu- 
lar masses,  tags,  and  partitions,  wash  out,  and  leave  a  stiff  soft-rubber 
drainage-tube  with  cross-bar.  Special  forceps  have  been  made  with 
which  the  abscess  may  be  opened  and  the  drainage-tube  carried  in.1 
The  puncturing  dilator  (Fig.  324)  and  the  blunt  dilator  (Fig.  325) 
are  also  serviceable  instruments  in  such  cases.  This  method  is  simple 
and  effective,  and,  as  a  rule,  successful,  but  has  the  drawback  that  one 
is  never  sure  of  not  wounding  a  blood-vessel  or  the  intestine.  It  is 
much  safer  to  cut  layer  after  layer  with  a  scalpel,  arresting  hemor- 
rhage, if  necessary,  by  carrying  a  suture  round  the  bleeding  vessels. 
(Compare  Hematocele,  p.  666.)  As  to  the  direction  of  the  incision,  if 
the  collection  is  central,  it  may  be  made  in  the  sagittal  or  coronal 
plane.  If  it  is  lateral,  the  incision  should  go  outward  and  backward, 
never  passing  the  prolongation  of  a  transverse  line  drawn  from  side 
to  side  through  the  cervical  canal,  in  order  to  steer  clear  of  the  ureter 
and  the  uterine  artery. 

If  the  abscess  points  near  Poupart's  ligament,  a  large  incision  is 
made  parallel  to  the  ligament,  cutting  layer  by  layer,  and  when  an 
opening  has  been  made  a  finger  is  introduced  to  the  bottom,  counter- 
pressure  is  made  from  the  vagina,  and,  if  there  is  not  too  much  tissue, 
a  counter-opening  is  made  here  and  a  soft  rubber  drainage-tube  with 
side  holes  drawn  through  the  cavity. 

This  incision  may  even  be  used  if  the  abscess  does  not  point,  but  is 
at  some  distance  from  the  ligament :  the  peritoneum  is  then  lifted 
until  the  abscess  can  be  entered  from  behind  without  opening  the 
peritoneal  cavity. 

When  the  pus  extends  upward  and  backward  (in  puerperal  cel- 
lulitis),  the  most  favorable  point  at  which  to  cut  deep  is  above  the 
crest  of  the  ilium,  between  the  attachments  of  the  latissimus  dorsi 
and  obliquus  abdominis  externus  muscles  (Petit's  triangle).  Here 
a  vertical  incision  is  made,  which  leads  to  the  external  border  of  the 
quadratus  lumborum  muscle. 

With  the  increasing  familiarity  with  laparotomy  it  becomes,  how- 
ever, more  and  more  customary  to  perform  that  operation.  It  has 
the  great  advantage  of  allowing  the  operator  to  see,  of  giving  him 
room  to  tie  bleeding  vessels,  to  remove  the  appendages  if  they  are 
found  to  be  the  source  of  the  suppuration,  and  to  empty  separate  pus- 
foci  wherever  they  may  be,  and  of  preventing  subsequent  infectioiii 
The  pus  should  be  aspirated  and  the  abscess-cavity  washed  out  with 
antiseptic  fluid  before  opening  it.  Even  then  the  place  where  the 
incision  is  to  be  made  should  be  surrounded  by  sponges  or  gauze  pads 

1  Dr.  Bache  Emmet  has  described  and  delineated  one  in  N.  Y.  Med.  Record,  March 
19,  1892. 


DISEASES  OF  THE  PELVIS.  667 

in  order  to  catch  the  contents.  If  the  abscess  unfortunately  bursts 
and  pus  enters  the  peritoneal  cavity,  it  should  be  wiped  off  with  gauze 
pads,  and  a  drain  of  iodoform  gauze  be  carried  from  the  contaminated 
part  through  the  wound  in  the  abdominal  wall  or  the  one  in  the  vagi- 
nal roof.  Only  if  the  pus  has  spread  far  away  among  the  intestinal 
knuckles,  the  cavity  should  be  flooded  with  a  warm  solution  of  salt 
(p.  502)  or  thymol,  or  with  Thiersch's  solution  (p.  206).  If  pos- 
sible, the  sac  is  stitched  to  the  edges  of  the  incision ;  if  not,  an 
opening  is  made  in  the  vaginal  vault,  drainage  is  established  in 
that  way,  and  the  abscess-cavity  is  closed  over  it ;  and  if  that  too 
is  impossible,  the  focus  is  simply  opened  and  disinfected,  and  a 
drainage-tube  or  iodoform-gauze  drain  is  brought  out  through  the 
abdominal  incision. 

Even  when  laparotomy  is  performed,  it  may  be  found  to  be  advan- 
tageous to  open  the  abscess  above  Poupart's  ligament  by  lifting  the 
peritoneum  and  getting  in  from  behind,  so  that  it  does  not  connect 
with  the  peritoneal  cavity. 

It  has  been  advised  to  open  abscesses  in  two  sittings  (Hegar's 
method).  An  incision  is  made  down  to  the  sac  without  opening  it ; 
the  wound  is  packed  with  iodoform  gauze,  which  is  left  in  for  four 
or  five  days  until  strong  adhesions  have  formed  all  around,  and  then 
the  abscess  is  opened.  This  method  is  applicable  both  to  abdominal 
and  vaginal  incision. 

Of  late  laparotomy  has  again  to  a  great  extent  been  replaced  by 
vaginal  hysterectomy  and,  if  possible,  removal  of  the  appendages.  If 
these  cannot  be  removed  and  contain  pus,  they  should  be  incised  and 
drained  through  the  vagina.  This  method  presents  the  advantage 
that  the  protecting  partition  which  nature  has  placed  between  the 
abscess  and  the  upper  part  of  the  peritoneal  cavity  need,  perhaps,  not 
be  broken,  and  that  there  is  established  free  drainage  through  the 
vagina.  On  the  other  hand,  the  removal  of  the  uterus  does  not  al- 
ways succeed,  and  still  less  that  of  the  appendages.  There  is  also 
considerable  danger  of  wounding  the  intestine  or  bladder,  and  the 
parts  are  so  little  accessible  between  the  hemostatic  pressure-forceps 
filling  the  .vagina  that  repair  becomes  impossible.  Often  the  re- 
moval of  the  uterus  is  facilitated  by  morcellation.  (Compare  Uter- 
ine Fibroid,  pp.  483-491.) 

Other  methods  have  been  proposed  in  order  to  reach  deep  abscesses 
from  the  perineal  or  sacral  region,  such  as  vertical  perineotomy,  trans- 
verse perineotomy,  and  sacrotomy. 

Vertical  Perineotomy. — An  incision  is  made  from  a  point  between 
the  posterior  and  middle  third  of  the  labium  majus,  going  midway 
between  the  anus  and  the  tuberosity  of  the  ischium,  and  ending 
somewhat  beyond  the  tuberosity.  In  this  way  the  levator  ani  muscle 
is  exposed  and  incised  in  order  to  reach  the  abscess. 


668  DISEASES  OF  WOMEN. 

Transverse  Perineotomy. — An  incision  is  made  from  one  tuberosity 
to  the  other,  and  carried  up  through  the  rectovaginal  septum. 

Sacrotomy. — This  is  Kraske's  method  for  extirpation  of  the  rec- 
tum or  Hegar's  modification  of  it  applied  to  the  opening  of  a  deep 
abscess.  (See  Hysterectomy,  pp.  519,  520.) 

None  of  these  methods  allows  the  operator  to  explore  the  pelvis 
to  any  great  extent,  and  still  less  to  remove  diseased  tissues  or  organs 
with  anything  like  the  facilities  afforded  by  laparotomy. 

To  use  the  blunt  curette  in  the  abscess,  except  in  cases  of  old 
standing,  is  hazardous,  since  we  have  seen  above  that  the  thickness 
of  the  sac  varies  much  in  different  parts,  and  a  perforation  might  be 
made  unawares  into  the  peritoneal  cavity. 

If  the  abscess  has  opened  into  the  bladder,  a  counter-opening  has 
been  made  in  this  viscus,  either  by  suprapubic  cystotomy  (Schroeder) 
or  from  the  vagina  (Buckmaster x),  in  order  to  establish  good  drain- 
age. But  it  often  closes  without  operation  by  simply  washing  out 
the  bladder. 

If  the  abscess  opens  into  the  ureter,  it  may  perhaps  be  possible  to 
repair  the  defect  by  laparotomy  (p.  375). 

After  an  abscess  has  been  emptied  and  well  drained,  the  surround- 
ing hard  masses  soon  disappear. 

Fistulous  Tracts. — After  spontaneous  opening  into  the  vagina  the 
abscess  heals  in  most  cases,  but  if  a  fistula  remains  and  constant  suppu- 
ration exhausts  the  patient,  it  must  be  dilated  with  the  knife,  dilator, 
or  tents ;  or  perhaps  a  laparotomy  may  give  the  best  access  to  the 
cavity.  Spontaneous  opening  near  Poupart's  ligament  or  the  iliac 
crest  often  leaves  long  sinuous  fistula?  that  have  to  be  dilated  with 
laminaria  or  laid  open  with  the  knife,  and  good  drainage  established, 
sometimes  by  means  of  a  counter-opening  in  the  vagina,  before  recov- 
ery can  take  place. 

Sometimes  it  suffices  to  curette  the  fistulous  tracts  and  old  abscess- 
cavities  that  will  not  close,  and  inject  them  daily  with  peroxide  of 
hydrogen,  carbolized  water  (2  per  cent.),  Labarraque's  solution  diluted 
with  8  or  10  parts  of  water,  Villate's  solution2  mixed  with  2  parts  of 
water,  or  to  use  two  or  three  times  a  week  injections  with  tincture 
of  iodine,  in  the  beginning  mixed  with  water,  or  a  solution  of  nitrate 
of  silver  (2  per  cent.). 

In  some  cases  of  adhesive  peritonitis  laparotomy  is  performed  with 
the  sole  aim  of  breaking  up  adhesions  (compare  Salpingitis,  p.  533)  ; 
but  if  it  is  done  for  a  pelvic  abscess,  the  tubes  and  ovaries  should,  if 
possible,  be  removed  as  the  source  of  the  suppurative  peritonitis. 

1  A.  H.  Buckmaster,  "Pelvic  Abscess,"  Brooklyn  Med.  Jour.,  April,  1891. 

2  R.  Cupri  sulphat,     \  da  ISO- 

Plumbi  sulphat.,  ( 

Liq.  plumbi  subacetat.,  30.0 ; 

Aceti,  200.0.— M. 


DISEASES  OF  THE  PELVIS.  669 

B.  Pelvic   Cellulitis. 

Pelvic  cellulitis  is  the  inflammation  of  the  connective  tissue  in  the 
pelvis  above  the  pelvic  diaphragm.  We  have  seen  in  the  anatomi- 
cal part  (p.  93)  that  there  is  a  large  amount  of  such  tissue  in  this 
locality,  and  especially  around  and  in  the  broad  ligaments,  and  that 
it  is  in  direct  connection  with  the  same  kind  of  tissue  outside  of  the 
abdominal  peritoneum  and  under  the  skin.  Some  modern  gynecolo- 
gists would  have  us  believe  that  inflammation  is  rare  in  this  tissue, 
and  that,  when  it  does  occur,  it  rarely  runs  into  suppuration.  It  is 
an  unfortunate,  but  common,  quality  of  the  human  mind  to  be  en- 
grossed by  one  idea  to  the  exclusion  of  others.  When  a  new  discovery 
is  made  we  are  apt  to  be  dazzled  by  it  to  such  a  degree  that  we  over- 
look other  equally  well-established  facts.  There  was  a  time  when 
every  pelvic  inflammation  was  looked  upon  as  cellulitis;  then  there 
came  a  reaction  and  it  was  all  peritonitis ;  and  of  late  many  exclusively 
lay  stress  on  salpingitis. 

As  a  matter  of  fact,  connective  tissue  in  the  pelvis,  just  as  anywhere 
else  in  the  body,  is  prone  to  become  inflamed ;  but,  as  a  rule,  we  have 
only  clinical  evidence  of  its  existence.  Since  the  patients  usually 
recover,  we  have  only  few  autopsies  to  fortify  our  argument  with.  Yet 
we  have  some  performed  on  women  in  which  the  inflammation  was 
strictly  confined  to  the  connective  tissue,  without  implicating  perito- 
neum, tube,  or  ovary ;  and  there  is  the  still  more  convincing  case  of 
a  man  who  fell  asleep  on  a  wet  bridge,  and  in  whose  pelvic  connective 
tissue  a  large  abscess  formed,  while  the  peritoneum  was  entirely  free.1 
In  this  case  certainly  no  puerperal  influence  could  be  invoked,  nor 
could  the  cellulitis  be  attributed  to  uterus,  tubes,  or  ovaries. 

Some  gynecologists  express  themselves  as  if  the  disease  did  not 
concern  them  when  it  is  connected  with  childbirth  and  abortion  ;  but, 
even  if  they  do  not  practice  obstetrics,  they  are  very  likely  to  be  called 
in  when  an  operation  has  to  be  performed,  and  science  is  one  inde- 
pendently of  the  limits  within  which  the  physician  may  find  it  con- 
venient to  confine  his  work.  But,  even  independently  of  puerperal 
influences,  cellulitis  exists,  and  if  we  do  not  see  it  in  laparotomies  as 
often  as  we  find  peritonitis,  it  is  for  the  simple  reason  that  few  lapa- 
rotomies are  performed  when  the  inflammation  is  limited  to  the  pelvic 
connective  tissue.2 

1  T.  H.  Burchard,  "  Pelvic  Abscess  in  the  Male,"  paper  read  before  the  X.  Y. 
Academy  of  Medicine,  April  15,  1886. 

2  It  is  beyond  the  scope  of  this  work  to  enter  into  controversies  or  to  give  a  com- 
plete bibliography,  but  those  who  want  to  study  the  question  of  pelvic  inflammation 
more  in  detail  will  find  it  to  their  advantage  to  examine,  among  others,  besides 
those  already  quoted,  the  following  papers:  "  On  the  Character  and  Types  of  Pelvic 
Inflammations  in  the  Female,"  by  Henry  S.  Stark,  Me<l.  Record,  Aug.  15,  1891  ; 
"  Perimetric  Cysts,"  by  John  Schmitt,  Amer.  Jour.  Obst.,  Jan.,  1892,  vol.  xxv.  p.  18  ; 
"  Peritonitis  hervorgerufen  durch  Ruptur  eines  Ovarialhiimatoms,"  by  II.  J.  Boldt, 


670  DISEASES  OF  WOMEN. 

Cellulitis  not  only  exists,  but  it  is  a  rather  common  occurrence, 
and  used  especially  to  be  so  before  antiseptic  midwifery  and  sur- 
gery were  so  much  practised  as  they  are  now-a-days.  Certain 
localities  are  more  liable  to  be  affected  than  others,  because  they  con- 
tain a  larger  amount  of  connective  tissue,  and  because  they  are  more 
exposed  to  injury — viz.  the  broad  ligaments,  the  surroundings  of  the 
lower  uterine  segment  and  the  fornix  of  the  vagina,  the  sacro-uterine 
ligaments,  and  the  space  between  the  cervix  and  the  bladder. 

Cellulitis  may  be  acute  or  chronic. 

Acute  cellulitis  may  arise  by  propagation  of  the  inflammation  from  a 
tear  or  ulcers  in  the  cervix  or  from  corporeal  endometritis,  the  inflam- 
mation spreading  through  the  intermuscular  connective  tissue.  It  may 
also  begin  directly  in  a  tear  extending  into  the  parametrium,  or  it  may 
begin  anywhere  in  the  depth  of  bruised  tissue.  In  most  cases  it  is 
combined  with  pelvic  peritonitis,  lymphangitis,  or  phlebitis. 

That  peritonitis  and  cellulitis  go  together,  whether  one  or  the  other 
is  the  primary  affection,  is  easy  to  understand,  since  the  peritoneum 
and  the  connective  tissue  are  not  only  in  contact,  but  the  peritoneum 
is  only  a  modification  of  connective  tissue. 

When  cellulitis  is  combined  with  lymphangitis,  the  latter  is  the  pri- 
mary lesion,  the  lymph-vessels  becoming  inflamed  in  the  uterus  or  in 

Deutsche  med.Wochenschrift,  1891 ;  "Unusual  Cases  of  Abdominal  Section."  by  Henry 
T.  Byford,  Chicago  Med.  Recorder,  Dec.  7, 1891 ;  "  Pus  in  the  Pelvis,  and  How'  to  Deal 
with  It,"  by  Joseph  Price,  Southern  Surgical  and  Gynecological  Trans.,  vol.  ii. ;  "  Ob- 
servations on  the  Medical  and  Surgical  Treatment.of  Peritonitis,"  by  T.  H.  Burchard, 
N.  Y.  Med.  Jour.,  Aug.  15,  1885 ;  "  Recurrent  Pelvic  Peritonitis,"  by  B.  F.  Baer, 
Med.  and  Surg.  Reporter,  Oct.  13,  1888  ;  "  Chronic  Adhesive  Perimetritis,"  by  James 
H.  Etheridge,  Chicago,  111.  (pamphlet  without  date) ;  "  Remarks  on  Peri-uterine  Cel- 
lulitis and  Peri-uterine  Peritonitis,"  by  H.  T.  Hanks,  Albany,  1885  ;  "  Electrolysis  in 
Peritoneal  Adhesions,"  by  W.  E.  Ford,  Med.  Press  of  Western  New  York,  April,  1888  ; 
"  The  Treatment  of  Local  and  General  Peritonitis,"  by  W.  E.  B.  Davis,  Med.  Asso- 
ciation of  the  State  of  Alabama,  April  13,  1890  ;  "Early  Operations  in  Purulent  Peri- 
tonitis," by  Joseph  Price,  Amer.  Med.  Assoc.,  May,  1890;  "The  Exaggerated  Im- 
portance of  Minor  Pelvic  Inflammations,"  by  H.  C.  Coe,  N.  Y.  Med.  Jour.,  May  15, 
1886  ;  "  The  Dangers  of  Leaving  the  Products  of  Inflammation  in  the  Female  Pel- 
vis," by  Chas.  P.  Noble,  Annals  of  Gynecology  and  Paediatrics,  July,  1891  ;  "Cases 
of  Neglected  Pus-tubes,"  by  the  same  author,  ibid.,  June,  1893,  p.  535  ;  "  Cases  of 
Post-partum  Pelvic  Abscess,"  by  T.  Johnson  Alloway,  Canada  Med.  and  Surgical 
Jour.,  Montreal,  1887 ;  "  Traumatic  Pelvic  Cellulitis,"  by  Thomas  H.  Allen,  Gail- 
lard's  Med.  Jour.,  Sept.,  1889  ;  "Some  Observations  upon  Pelvic  Cellulitis,"  by  Vir- 
gil O.  Hardon,  Atlanta  Medical  and  Surgical  Jour.,  1887  ;  "  Pelvic  Abscess,"  by  A. 
H.  Bnckmaster,  Brooklyn  Med.  Jour.,  April,  1891  ;  "  Case  of  Pelvic  Abscess,"  by  H. 
T.  Byford,  Chicago  Gyn.  Soc.,  Dec.  18,  1885,  Chicago,  1886;  "Treatment  of  Pelvic 
Abscess  in  Women,"  by  P.  F.  Mtinde",  Amer.  Jour.  Obst.,  1886,  vol.  xiz.  p.  113; 
"Peri-uterine  Inflammation,"  by  W.  M.  Polk,  Med.  Record,  Sept.  18,  1886,  vol. 
xxx.,  p.  309  ;  Pelvic  Peritonitis— Microscopical  Studies,"  by  Mary  Dixon  Jones,  Med. 
Record,  May  28, 1892  ;  "  Septic  Endometritis  and  Peritonitis,"  by  W.  R.  Pryor,  Amer. 
Jour.  Obst.,  vol.  xxv.  p.  598,  May,  1892;  "  Remarks  upon  Parametritis,"  by  Geo.  T. 
Harrison,  Amer.  Jour.  Obst.,  April,  1891,  vol.  xxiv.  p.  460 ;  "  How  shall  we  Treat 
our  Cases  of  Pelvic  Inflammation?"  by  Richard  B.  Maury,  Amer.  Jour.  Obst.,  vol. 
xxiv.,  Jan.,  1891. 


DISEASES  OF  THE  PELVIS.  671 

the  tear  of  the  cervix,  and  carrying  the  infection  through  and  into  the 
connective  tissue. 

Phlebitis  may  be  primary,  extending  from  inflamed  uterine  sinuses, 
or  secondary,  beginning  as  periphlebitis  by  contact  with  inflamed 
connective  tissue,  and  gradually  gaining  the  deeper  coats  of  the  vein. 

Cellulitis  is  seldom  bilateral. 

We  may  distinguish  between  a  simple  traumatic  form  and  a  septic 
form.  Both  are  due  to  infection  with  bacteria,  but  in  the  first  simple 
bacteria  of  putrefaction  are  at  work ;  in  the  second  we  have  to  deal 
with  specific  pathogenic  bacteria. 

Either  of  these  forms  may,  again,  be  puerperal  or  non-puerperal. 
The  traumatic  extends  in  the  loose  connective  tissue,  following  the 
interstices  between  sheets  of  hard  connective  tissue;  the  septic 
respects  no  boundaries. 

As  in  other  inflammations,  we  may  distinguish  different  stages,  one 
of  infiltration,  followed  by  one  of  resolution,  suppuration,  or  organ- 
ization. 

During  the  stage  of  infiltration  the  connective  tissue  is  swollen  by 
exudation  of  serum  and  formation  of  small  round  cells,  which  change 
the  tissue  into  a  gelatinous  yellow  mass.  In  most  cases  the  serous  fluid 
and  the  form-elements  disappear  again  in  the  course  of  two  or  three 
weeks.  In  others  pus  is  formed,  and  of  all  perimetric  inflammations 
cellulitis  is  the  one  which  most  frequently  ends  in  suppuration. 
Often  the  melting  into  pus  takes  place  at  several  distinct  points,  and 
it  is  only  in  the  course  of  time  that  these  separate  foci  unite  into  one 
large  abscess-cavity.  As  to  the  routes  followed  by  the  pus  and  the 
point  where  the  abscess  breaks,  the  reader  is  referred  to  what  has  been 
said  above  in  speaking  of  pelvic  abscess  in  general  (p.  659).  Here 
we  shall  only  add  that  while  a  puerperal  abscess  commonly  finds  an 
outlet  through  the  skin ; — breaking  above  Poupart's  ligament  or,  more 
rarely,  below  the  same;  following  the  vagina  down  to  the  labium 
majus  and  the  anus;  going  through  the  obturator  foramen  or  the 
greater  sacro-sciatic  foramen  ;  or  following  the  round  ligament  through 
the  inguinal  canal ; — the  non-puerperal  very  rarely  perforates  the  skin, 
and  is  usually  discharged  into  one  of  the  hollow  organs  in  the  pelvis. 

The  abscess  in  the  connective  tissue  rarely  ruptures  into  the  peri- 
toneal cavity,  fatal  peritonitis  being,  as  a  rule,  due  to  simple  extension 
of  the  inflammation  to  the  peritoneum. 

Cellulitis  often  leads  to  uterine  displacement,  cicatricial  retraction 
of  the  sacro-uterine  ligaments  causing  anteflexion  (p.  439),  and  that 
of  the  broad  ligament  lateroversion  (p.  454). 

If  the  inflammation  ends  in  organization,  pus  may  still  form  in  the 
indurated  tissue  after  a  long  time. 

Chronic  Cellulitis. — Chronic  cellulitis  is  found  as  a  remnant  of  the 
acute  form  in  the  shape  of  cicatrices,  indurated  bands,  discharging 


672  DISEASES  OF  WOMEN. 

abscesses,  and  fistulous  tracts.  It  may  also  be  an  originally  chronic 
cirrhosis  (atrophic  chronic  cellulitis),  which  will  be  described  later. 

Etiology. — Acute  cellulitis  is  not  found  in  childhood,  and  is  rare 
after  the  menopause.  It  is  confined  to  the  age  of  sexual  maturity,  and 
especially  to  the  puerperal  state. 

Puerperal  cellulitis  may  be  due  to  a  tear  in  the  cervix  in  an  other- 
wise normal  labor;  but  is  especially  caused  by  obstetric  operations, 
such  as  forced  dilatation  of  the  cervix  or  the  extraction  of  the  child 
with  forceps  through  a  narrow  pelvis.  It  may  join  inflammation  of 
the  uterus,  tubes,  and  ovaries.  Sometimes  a  hematoma — puerperal  or 
non-puerperal — is  first  formed,  which  later  suppurates. 

Non-puerperal  cellulitis  is  due  to  the  use  of  tents,  over-distention 
and  other  operations  on  the  cervix,  enucleation  of  tumors,  or  the 
presence  of  a  non-puerperal  hematoma.  But,  finally,  all  these  cases 
are  due  to  infection,  and  the  difference  in  their  course  depends  on  the 
different  kinds  of  microbes  at  work,  especially  the  difference  between 
common  bacteria  of  putrefaction  and  specifically  pathogenic  micro- 
cocci. 

Cellulitis  may  also  be  brought  on  by  exposure  to  cold. 

Symptoms. — The  symptoms  are  much  like  those  of  peritonitis,  but 
with  certain  differences.  The  patient  may  have  a  chill ;  there  is  a 
rise  in  temperature ;  her  pulse  becomes  frequent ;  her  tongue  is 
furred  ;  she  feels  weak ;  she  has  no  appetite  ;  she  has  pain  in  the  lower 
part  of  the  abdomen,  and,  perhaps,  vesical  or  rectal  tenesmus ;  but  the 
pain  is  not  so  sudden  nor  so  severe  as  in  peritonitis ;  there  is  less 
tendency  to  vomiting,  and  no  distention  of  the  abdomen.  On  vaginal 
examination  we  find  heat,  swelling,  and  considerable  tenderness.  If 
the  broad  ligament  is  the  seat  of  the  disease,  we  feel  a  tumor  varying 
in  size  between  a  walnut  and  an  apple.  If  sufficiently  large,  it  pushes 
the  uterus  over  to  the  opposite  side.  If  the  inflammation  is  bilateral, 
the  uterus  is  lifted  up,  and  often  the  two  lateral  tumors  may  be  felt 
connected  by  a  bridge  in  front  and  behind  the  cervix.  If  the  con- 
nective tissue  around  the  sacro-uterine  ligaments  is  affected,  we  feel 
the  semilunar  fold  forming  the  upper  limit  of  Douglas's  pouch 
swollen  on  one  or  both  sides.  Occasionally  the  swelling  may  be 
limited  to  the  connective  tissue  behind  or  in  front  of  the  cervix 
(posterior  or  anterior  cellulitis).  If  the  inflammation  extends  to  the 
iliac  fossa,  the  corresponding  leg  is  drawn  up. 

Transition  to  pus  is  marked  by  the  swelling  becoming  soft,  but 
hardly  distinctly  fluctuating. 

Induration  of  the  tissue  may  last  for  many  months.  Often  irrita- 
bility of  the  bladder  continues  after  the  fever  and  swelling  have  sub- 
sided— a  symptom  which  is  referable  to  shortening  of  the  sacro-ute- 
rine ligaments,  which  pull  on  the  cervix  and  indirectly  on  the  base  of 
the  bladder,  which  is  bound  to  it  with  a  thin  layer  of  connective  tissue. 


DISEASES  OF  THE  PELVIS. 


673 


As  to  other  sequels,  we  may  find  amenorrhea,  menorrhagia,  or 
dysmenorrhea. 

Diagnosis. — Enough  has  been  said  under  the  Symptomatology  and 
in  speaking  of  pelvic  peritonitis  (p.  662)  about  the  difference  be- 
tween cellulitis  and  the  latter  disease.  Hematoma  begins  suddenly 
without  fever  and  with  great  pain.  An  inflamed  ovarian  tumor  may 
be  very  hard  to  differentiate  except  by  the  history  and  later  course  of 
the  disease.  A  common  ovarian  tumor  is  movable.  A  uterine  fibroid 
forms  one  mass  with  the  uterus  and  moves  with  it,  whereas  in  cellu- 
litis it  is  possible  to  feel  a  groove  between  that  organ  and  the  swelling 
in  the  broad  ligament,  and  the  uterus  is  more  or  less  immovable. 
Retroperitoneal  sarcoma  is  a  chronic  disease,  in  which  the  constitution 
soon  suffers. 

Prognosis. — The  prognosis  of  cellulitis  is  less  grave  than  that  of 
peritonitis.  It  may,  however,  become  fatal  in  a  short  time  through 
septicemia  or  develop  into  the  more  dangerous  peritonitis.  As  a 
rule,  the  prognosis  is  good  as  to  life,  but  very  uncertain  as  to  time 
and  complete  recovery. 

Treatment. — All  that  has  been  said  above  about  the  treatment  of 
peritonitis  (p.  663,  et  seq.)  applies  to  cellulitis,  whether  an  abscess  is 
formed  or  not.  I  shall,  therefore,  limit  myself  to  a  few  additional  re- 
marks bearing  especially  upon  cellulitis. 

Prophylaxis  consists  in  avoidance  of  refrigeration  and  in  antiseptic 
midwifery  and  surgery.  Slowly  dilating  tents  should,  as  far  as  possi- 
ble, be  discarded,  and  replaced  by  rapid  dilatation  with  steel  dilators. 

Instead  of  the  hot  douche,  some  recommend  a  continuous  current 
of  ice-water,  beginning  at  a  pleasantly  warm  temperature  and  dimin- 
ishing the  heat  gradually ;  and,  to  judge  by  the  superiority  of  the 
ice-bag  over  the  poultice  in  other  inflammations,  the  advice  seems 
worthy  of  trial.  This  injection  can  easily  be  administered  through 

FIG.  331. 


Frost's  Vaginal  Syringe. 


Frost's  vaginal  syringe  (Fig.  331),  which  plugs  the  vagina  and  has 
an  efferent  tube  leading  down  to  a  vessel  under  the  bed. 

If  pus  begins  to  form,  the  maturation  of  the  abscess  should  be  fur- 
thered by  the  use  of  warm  abdominal  poultices  and  vaginal  injections. 


674  DISEASES  OF  WOMEN. 

Some  recommend  early  aspiration  in  several  places  through  the 
vaginal  roof,  by  which  a  small  amount  of  bloody  serum  is  with- 
drawn, but  the  discomfort  unavoidably  connected  with  the  operation 
and  the  danger  of  infection  make  other  means  of  promoting  absorption 
preferable.  If  pus  is  formed,  aspiration  is  hardly  radical  enough  to 
produce  a  cure. 

When  pus  begins  to  form  in  several  foci,  it  is  best  to  give  them 
time  to  unite  before  opening  the  abscess. 

If  pus  follows  the  round  ligament,  the  operator  may  succeed  in 
introducing  a  glass  drainage-tube  through  the  inguinal  canal. 

If  an  abscess  forms  between  the  uterus  and  the  bladder,  it  must  be 
opened  very  cautiously  by  a  T-shaped  incision  in  the  vagina. 

An  abscess  in  the  broad  ligament  may  be  reached  by  partial  excis- 
ion of  the  uterus.1  First  the  cervix  is  removed,  and  then  so  much 
of  the  body  cut  away  that  the  finger  can  be  introduced  into  the 
abscess-cavity.  Hemorrhage  is  exclusively  controlled  by  hemostatic 
forceps,  which  are  left  in  place  for  forty-eight  hours.  This  method 
would  only  be  available  in  women  with  a  large  vagina. 

Some  go  even  so  far  as  to  perform  total  vaginal  hysterectomy  in 
order  to  reach  a  purulent  collection  in  the  pelvis,  whether  situated  in 
the  connective  tissue  or  elsewhere.2  It  was  doubtless  a  great  progress 
when  Pean  in  1890  introduced  vaginal  hysterectomy  for  large  puru- 
lent collections  in  the  pelvis,  and  invented  a  new  technique  for  its 
performance.  This  was  the  starting-point  of  the  new  vaginal  method 
as  opposed  to  the  abdominal  section,  which  had  reigned  since  1872. 
But,  as  in  the  beginning,  many  appendages  were  extirpated  which 
might  have  been  cured  or  were  not  diseased ;  doubtless  many  uteri 
now  share  their  fate,  and  the  vaginal  method  is  probably  sometimes 
more  used  for  display  of  the  surgeon's  dexterity  than  because  the  ope- 
ration is  done  better  and  more  safely  by  that  method  than  by  lapa- 
rotomy.  (Compare  Pelvic  Abscess,  p.  667.)  In  regard  to  the  technique 
the  reader  is  referred  to  the  description  of  vaginal  hysterectomy  by 
the  clamp  method  (p.  483). 

In  a  case  of  pelvic  abscess  that  had  opened  into  the  bladder  recov- 
ery was  obtained  by  making  an  artificial  vesico-vaginal  fistula,  dilat- 
ing the  opening  between  the  bladder  and  the  abscess,  thrusting  a  pair 
of  scissors  in  front  of  the  cervix  into  the  abscess,  dilating  the  opening 
thus  made,  and  fastening  a  drainage-tube  there.3 

Chronic  Atrophic  Cellulitis* — It  consists  in  a  cirrhotic  contraction 

1  Landau,  CentraJblatt  fur  Gyndkologif,  1892,  No.  35,  vol.  xvi.  p.  689. 

2  Pe"an,  Bulletin  de  I' Academic  de  Medecine,  No.  27, 1890 ;  Segond,  "  De  1'Hystdrec- 
toniie  vaginale  dans  le  Traitement  des  Suppurations  pelviennes,"  Revue  de  Chirurgie, 
1891,  No.  4, 

3  A.  H.  Buckmaster,  Brooklyn  Med.  Jour.,  April,  1891. 

4  This  disease  has  been  described  by  Wilhelm  A.  Freund  in  Gynak.  Klinik,  vol.  i. 
pp.  239-326,  Strassburg,  1885. 


DISEASES  OF  THE  PELVIS.  675 

and  hardening  of  the  pelvic  connective  tissue,  like  that  taking  place 
in  the  kidneys,  liver,  spleen,  lungs,  and  other  organs.  It  appears  in 
a  circumscribed  and  diffuse  form.  The  circumscribed  is  due  to  ulcers 
in  the  bladder  and  the  rectum,  laceration  of  the  cervix,  or  chronic 
raetritis.  The  induration  is  situated  on  a  level  with  the  so-called 
superior  sphincter.  On  the  anterior  wall  of  the  vagina,  correspond- 
ing to  the  base  of  the  bladder,  is  found  a  stellate  cicatrice,  from  which 
the  induration  can  be  followed  more  or  less  far  into  the  surrounding 
parts.  This  condition  is  combined  with  congestion  of  the  hemor- 
rhoidal  veins.  The  diffuse  form  starts  from  the  base  of  the  broad 
ligament,  and  may  extend  through  the  whole  pelvis.  The  Arteries 
are  diminished  in  size ;  the  veins  are  either  narrowed  or  dilated,  and 
contain  often  thrombi  or  phleboliths.  It  leads  to  venous  congestion 
and  varicosities,  atrophy  and  sclerosis  of  the  uterus,  and  synechise 
between  the  walls  of  the  cervix.  The  vagina  is  shortened,  and  often 
funnel-shaped.  The  cervical  ganglion  (p.  62)  is  covered  and  inter- 
spersed with  cicatricial  tissue. 

The  causes  of  the  diffuse  form  are  the  same  as  those  of  the  circum- 
scribed or  too  great  or  too  frequent  sexual  excitement,  especially  mas- 
turbation, and  losses  through  hemorrhage  and  leucorrhea.  Chlorotic 
women  with  hypoplasia  of  the  genitals  and  the  circulatory  system  are 
particularly  predisposed  to  it. 

Symptoms. — Patients  affected  with  chronic  atrophic  cellulitis  have 
a  decided  propensity  to  masturbation,  with  indifference,  or  even  aver- 
sion, for  coition.  They  suffer  often  from  erotic  dreams,  with  emis- 
sions of  mucus.  They  complain  of  pain  in  the  iliac  fossa,  dyschezia, 
dysuria,  dysmenorrhea,  often  intermenstrual  pain  (p.  417),  and  always 
present  hysterical  symptoms,  among  others  copiopia  hyst erica  (p.  247). 

Prognosis. — The  circumscribed  form  may  be  cured  when  the  cause 
is  removed,  and  especially  if  pregnancy  supervenes.  The  diffuse  is 
incurable,  but  may  remain  stationary  for  long  periods. 

Treatment. — The  causes  must  be  removed,  the  vagina  treated  with 
iodine  glycerin  or  ichthyol  glycerin  and  packing,  and  cicatrices  cut  out 
or  incised  and  stretched  (p.  354).  The  many  reflex  neuroses  are  treated 
as  hysteria,  especially  with  nitrate  of  bismuth,  nitrate  of  silver,  acetate 
of  zinc,  ammonia,  castoreum,  and  valerian.  During  the  hysterical 
attack  nothing  should  be  done,  as  any  interference  only  serves  to 
make  the  condition  worse.1 

C.  Pelvic  Phlebitis. 

Pelvic  phlebitis  is  a  rare  disease.  It.  is  primary  in  puerperal  cases, 
the  inflammation  starting  in  the  sinuses  of  the  uterus.  In  this 

1  In  this  connection  it  is  quite  interesting  that  Freund  states  that  in  Strasshurg  they 
do  not  see  the  attacks  described  by  Charcot  in  Paris— an  experience  which  is  shared 
by  many  others  in  other  places. 


676  DISEASES  OF  WOMEN. 

variety  the  inflammation  begins  in  the  internal  coat,  and  soon  a 
thrombus  forms  in  the  lumen.  The  inflammation  spreads  outward, 
and  may  implicate  the  connective  tissue. 

In  non-puerperal  cases  it  is  exceedingly  rare,  and  begins  as  peri- 
phlebitis,  an  affection  following  secondarily  on  acute  cellulitis. 

Congestion  of  the  pelvic  veins  is  very  common,  and  the  presence 
of  phleboliths  in  the  veins  at  the  base  of  the  broad  ligament  is  not  a 
rare  occurrence.  This  congestion,  which  must  not  be  confounded 
with  phlebitis,  is  often  much  relieved  by  lifting  the  uterus  with  a 
pessary,  and  thereby  giving  a  straighter  course  to  the  veins. 

Pelvic  phlebitis  blends  always  with  cellulitis,  and  clinically  they 
cannot  be  distinguished. 

,    D.  Pelvic  Lymphangitis  and  Lymphadenitis. 

In  the  anatomical  part  (p.  62)  we  have  seen  that  the  uterus  is 
exceedingly  rich  in  lymph-spaces  and  lymph-vessels,  uniting  in  trunks 
which  traverse  the  broad  ligament  and  lead  to  the  different  glands 
in  the  pelvis.  The  lymphatics  from  the  upper  three-fourths  of  the 
vagina  go  the  same  way,  while  those  from  the  vulva  and  the  lower 
fourth  of  the  vagina  go  to  the  superficial  inguinal  glands,  that  com- 
municate with  the  deep  inguinal  glands,  from  which  other  vessels  go 
to  the  external  iliac  glands.  Those  from  the  tube  and  the  ovary 
traverse  the  broad  ligament,  and  go  through  the  infundibulopelvic 
ligament  to  the  lumbar  glands. 

The  inflammation  may  extend  from  any  part  of  the  genital  tract 
into  the  broad  ligament  and  the  peritoneum,  causing  lymphangitis, 
lymphadenitis,  cellulitis,  or  peritonitis. 

The  lymphatic  vessels  play  a  very  important  part  in  the  propaga- 
tion of  infection  in  the  puerperal  state,1  and  the  inflammation  follow- 
ing is  then  acute. 

In  non-puerperal  cases  lymphangitis  and  lymphadenitis  also  exist, 
but  seem  to  be  rare,  or  so  blended  with  other  pelvic  inflammations 
that  they  seldom  can  be  discovered.  Many  authors  do  not  mention 
the  affection  at  all ;  others  have  little  to  say  about  it  or  are  doubtful  as 
to  its  existence.  In  a  gynecological  practice  extending  over  more  than 
twenty  years,  in  which  I  have  examined  I  do  not  know  how  many  thou- 
sand women,  I  have  never  found  a  case  myself,  unless  a  few  in  which 
the  gland  on  the  side  of  the  isthmus  was  swollen  belonged  to  this  cate- 
gory. One  was  kindly  demonstrated  to  me  by  Dr.  P.  F.  Munde'  in 
1883,  but,  although  I  felt  the  small  tumors  behind  the  uterus,  I  am 
not  sure  that  they  were  swollen  lymphatic  glands.  But  the  disease 
having  been  described  by  such  excellent  observers  as  Courty,  Cham- 
pionni£re,  Munde",  A.  Martin,  and  others,  each  of  whom  claims  to 

1  See  Garrigues,  "  Puerperal  Infection,"  Hirst's  Amer.  System  of  Obstetrics,  vol.  iL 
pp.  290-378. 


DISEASES  OF  THE  PELVIS.  677 

have  seen,  if  not  many,  at  least  a  certain  number  of  cases,  I  do  not 
doubt  its  existence,  and  shall  here  give  a  resume*  of  their  descriptions. 

The  non-puerperal  form  is  either  acute  or  chronic,  more  frequently 
the  latter.  Lymphadenitis  is  characterized  by  the  occurrence  of  small, 
rounded,  irregular,  uneven  tumors,  varying  in  size  from  a  pea  to  a 
small  hazelnut,  and  situated  to  the  sides  of  the  isthmus  of  the  uterus, 
more  frequently  on  the  right,  or  on  the  posterior  surface  of  the  uterus. 
They  are  loosely  connected  with  the  latter  and  the  vagina.  Most 
authors  claim  only  to  have  felt  from  one  to  three  such  tumors,  but 
Munde*  has  found  at  least  twenty1  on  the  posterior  surface  of  the 
uterus,  and  Martin  speaks  of  glands  in  the  broad  ligaments  forming 
rows  like  strings  of  pearls  of  moderate  size.2 

Now,  there  is  this  objection  to  the  theory  of  looking  upon  these 
tumors  as  glands,  that  only  those  glands  which  I  have  mentioned  in 
the  anatomical  part  have  been  found  in  the  pelvis  by  anatomists — 
namely,  Charnpionni&re's  gland  at  the  side  of  the  isthmus,  the  obtu- 
rator gland,  the  external  iliac  glands,  the  internal  iliac  glands,  and 
the  sacral  glands.  On  the  posterior  surface  of  the  uterus  there  are 
none ;  but,  on  the  other  hand,  there  are  large  plexuses  of  lymphatic 
vessels  ;  and  those  small  tumors  felt  clinically  above  the  posterior 
vault  of  the  vagina  are  probably  clusters  of  swollen  lymph-vessels  or 
pouch-like  dilatations  of  such  vessels,  just  as  we  find  them  in  puer- 
peral cases,  in  which  they  may  reach  the  size  of  a  cherry.  The  same 
explanation  holds  good  for  the  rows  of  swellings  felt  in  the  broad 
ligament. 

A  third  possibility  is  that  the  small  tumors  may  be  due  to  local- 
ized perilymphatic  inflammation. 

A.  Martin  thinks  that  cellulitis  often  begins  as  lymphadenitis,  the 
gland  suppurating  and  pouring  its  contents  into  the  connective  tissue 
of  the  broad  ligament.  Even  without  such  suppuration  and  rupture 
it  is  very  likely  that  cellulitis  often  starts  from  perilymphangitis. 

Etiology. — The  inflammation  of  the  lymphatics  is  caused  by  endo- 
metritis — either  catarrhal  or  non-specific  purulent  or  gouorrheal. 
Lymphadenitis  may  also  be  due  to  syphilis  or  scrofula,  when  it  is 
apt  to  be  combined  with  adenitis  in  other  parts  of  the  body. 

Symptoms. — The  patient  complains  of  a  pain  deep  in  the  pelvis, 
rather  to  one  side,  especially  the  right,  extending  to  the  pubes  and  the 
obturator  foramen  or  downward  and  backward  to  the  coccyx,  and  of 
a  tenderness  rendering  coition  painful.  There  is  no  rise  in  tem- 
perature. The  parametrium  is  swollen  and  tender,  but  without 
effusion.  The  uterus  is  movable,  but  its  movement  causes  pain.  It 
is  enlarged,  tender,  and  often  retroflexed.  The  ovaries  are  also 
swollen  and  tender.  Behind  and  to  the  sides  of  the  uterus  are  felt 

1  P.  F.  Mund£,  Amer.  Jour.  Obst.,  1883,  vol.  xvi.  p.  1018. 

2  A.  Martin,  Frauenkrankheiten,  p.  323. 


678  DISEASES  OF   WOMEN. 

the  above-described  small  tumors,  which  are  very  tender  and  some- 
what movable,  or  a  bundle  of  tender,  movable  cords  which  impart 
a  feeling  like  a  bunch  of  angle-worms.1 

Diagnosis. — The  tumors  are  much  smaller  and  situated  lower  down 
than  the  ovary,  not  so  movable,  and  when  pressed  do  not  cause  the 
sickening  pain  elicited  by  pressure  on  the  sexual  gland. 

Their  own  mobility  and  the  mobility  of  the  womb  distinguish 
them  from  cellulitis. 

The  movable,  worm-like  cords  are  pathognomonic  of  lymphangitis. 

Treatment. — When  endometritis  is  the  cause,  it  should  be  treated 
according  to  the  rules  laid  down  for  that  disease  (pp.  405  and  412). 
Iodine  (p.  170)  and  ichthyol  glycerin  (p.  178)  should  be  used  in  the 
vagina.  Packing  of  the  vagina  (p.  178)  gives  much  relief  and  makes 
the  swelling  disappear.  lodoform  suppositories  (p.  226)  are  useful 
both  as  anodynes  and  as  resolvents.  It  is  recommended  to  use  inunc- 
tions of  Ung.  hydrargyri  (20  parts)  and  Ext.  belladonnse  (1  part)  on 
the  hypogastric  region.  Galvanism  has  also  proved  beneficial.  In 
extreme  cases  it  may  be  justifiable  to  try  to  favor  involution  of  the 
hyperplastic  uterus  by  amputation  of  the  cervix  (p.  418).  If  the 
patient  is  affected  with  scrofula  or  syphilis,  the  usual  remedies  for 
those  diseases  should  be  combined  with  the  local  treatment. 


CHAPTER  VIII. 

SARCOMA  AND  CARCINOMA  OF  THE  PELVIC  PERITONEUM  AND 
CONNECTIVE  TISSUE. 

CANCER  of  the  pelvis  is  usually  only  part  of  a  similar  affection 
spread  over  a  larger  territory  or  a  direct  propagation  by  continuity 
from  neighboring  organs.  Thus,  carcinoma  of  the  broad  ligament 
appears  in  connection  with  the  same  affection  in  other  parts  of  the 
peritoneum,  or  begins  as  carcinoma  of  the  uterus  or  the  ovary.  But 
both  sarcoma  and  carcinoma  may  start  as  a  primary  disease  in 
Douglas's  pouch,  and  carcinoma  may  begin  in  the  lymphatic  glands. 

Sarcoma  may  form  a  large  tumor  behind  the  uterus,  pushing  this 
organ  forward.  Medullary  carcinoma  often  appears  as  a  relapse  in 
the  cicatrix  after  removal  of  the  carcinomatous  uterus. 

The  malignant  nature  of  these  affections  is  proved  by  the  cachexia 
which  rapidly  follows  their  advent.  It  is  rarely  possible  to  do  any- 
thing of  therapeutical  value  for  them,  except  in  the  cases  of  relapse 

1  The  great  tenderness  of  the  tumors,  even  in  chronic  cases,  speaks  also  against 
their  being  glands,  for  chronically  inflamed  lymph-glands,  which  are  so  common  in 
scrofula  and  syphilis,  are  not  sensitive  to  touch. 


DISEASES  OF  THE  PELVIS.  679 

after  hysterectomy.  A  patient  who  has  had  her  uterus  extirpated 
should  be  examined  every  few  months  for  many  years,  and  as  soon  as 
a  local  relapse  appears  the  diseased  tissue  should  be  cut  away  and  the 
wound  cauterized.1 


CHAPTER  IX. 
HYDATIDS  (Ecmxococci)  OF  THE  PELVIS. 

HYDATIDS  are  so  rare  that  few  physicians  have  had  opportunity  to 
see  a  case,2  but  of  the  entire  number  reported  4  per  cent,  were  situated 
in  the  pelvis ;  and  the  disease  is  by  far  more  common  in  women  than 
in  men.3 

Pelvic  hydatids  are  most  common  in  the  connective  tissue  of  the 
posterior  part  of  the  pelvis  near  the  rectum,  but  are  also  found  in  the 
uterus,  the  ovaries,  the  broad  ligaments,  the  anterior  part  of  the  pel- 
vis, and  anywhere  in  the  bones.  As-  a  rule,  the  animal  consists  of  a 
mother-cyst  with  endogenous  or  exogenous  daughter-cysts.  The  mul- 
tilocular,  or  alveolar,  form  has  never  been  found  in  the  pelvis. 

The  echinococcus  may  enter  the  pelvis  as  a  germ  or  reach  it  by 
extension  from  another  part  of  the  abdomen.  Beginning  in  the  pel- 
vis, the  cyst  may  rise  above  the  superior  strait  or  follow  the  connect- 
ive tissue  of  the  pelvis,  press  down  on  the  perineum,  grow  out  through 
the  great  sacro-sciatic  foramen  or  the  crural  canal,  and  extend  up  on 
the  anterior  wall  of  the  abdomen.  In  consequence  of  pressure  from 
neighboring  organs  the  animal  may  die,  the  fluid  become  turbid,  puru- 

1  Dr.  M.  D.  Jones  has  reported  a  case  in  which  a  carcinomatous  tumor  of  the  size 
of  an  orange  in  the  pelvic  floor  was  combined  with  a  similar  affection  of  the  ovaries. 
She  removed  all  the  diseased  tissue,  and  made  a  microscopical  examination  that  is 
of  great  interest,  because  it  proves  that  the  so-called  inflammatory  infiltration  that 
surrounds  a  carcinoma  to  a  distance  of  a  quarter  to  half  an  inch  is  in  reality  a  pre- 
cursory stage  of  carcinomatous  infiltration,  the  inflammatory  corpuscles  shaping  them- 
selves into  the  epithelial  cells  characteristic  of  carcinoma,  and  that  the  disease  spreads 
by  such  cancer-cells  being  transmitted  into  the  lymphatics  and  causing  thrombosis 
of,  and  carcinomatous  infection  around,  them  (Medical  Record,  March  11,  1893,  vol. 
xliii.  p.  292). 

2  Personally,  I  have  only  seen  one  case,  and  that  was  in  the  liver  (Proceeding*  of 
the  Medical  Society  of  Kings,  Brooklyn,  N.  Y.,  1876,  vol.  i.  No.  5,  p.  123V      In  the 
above  description  I  chiefly  follow  W.  A.  Freund,  who,  living  for  many  years  in  an 
echinococcus  district,  has  had  the  rare  opportunity  of  treating  eighteen  cases  of 
hydatid  disease  in  the  true  and  false  pelvis,  and  who  has  described  them  in  his 
Klinik  der  Gyntikologie,  vol.  i.  pp.  299-326.     Four  of  these  he  has  previously  described, 
conjointly  with  J.  K.  Chadwick  of  Boston  (Amer.  Jour.  Obst.,  Feb.,  1875,  vol.  vii.  pp. 
668-679). 

3  The  Icelandic  physician  Jon  Finsen  personally  treated  245  cases  of  echinococcus 
disease.     Of  these,  172,  or  more  than  70  per  cent.,  were  in  the  female  sex  (  Ugeskrift 
for  Lceyer,3d  series,  3d  vol.  Nos.  5-8,  Copenhagen,  1867).     A  French  translation, 
made  by  myself  from  the  Danish  original,  is  found  in  Archives  generales  de  Medentie, 
Jan.  and  Feb.,  1869,  vol.  i.  pp.  23-46  and  191-210). 


680  DISEASES  OF  WOMEN. 

lent,  or  sanious,  and  the  vesicles  be  broken  up  into  shreds.  Rupture 
may  take  place  into  the  bladder,  or  exceptionally  into  the  uterus  or  the 
vagina,  but  never  into  the  peritoneal  cavity — the  peritoneum,  on  the 
contrary,  always  becoming  thickened.  Such  rupture  may  lead  to  a  cure. 

Etiology. — The  disease  is  due  to  the  entrance  into  the  body  of  the 
eggs  of  the  Tcenia  echinocoecus  of  the  dog.  As  a  rule,  the  entrance 
takes  place  through  the  mouth,  but  some  women  allowing  their  geni- 
tals to  be  licked  by  dogs  for  libidinous  purposes,  it  is  not  impossible 
that  the  germs  might  be  brought  directly  into  the  genital  tract  instead 
of  passing  through  the  alimentary  canal.  The  disease  is  endemic  in 
certain  parts  of  the  world,  such  as  Australia,  Iceland,  Mecklenburg, 
and  Silesia. 

Symptoms. — The  disease  may  exist  for  years  without  impairing  the 
general  health  or  even  causing  much  local  trouble.  Attention  is  first 
called  to  it  when  it  causes  dyschezia,  dysuria,  or  dystocia,  and  often 
it  gives  rise  to  leucorrhea  or  menorrhagia.  Later  the  nutrition  suf- 
fers, the  patient  loses  flesh,  and  she  may  become  feverish,  either  when 
suppuration  sets  in  or  when  the  constitution  becomes  undermined.  In 
consequence  of  pressure  her  feet  may  swell,  her  legs  become  paralyzed, 
she  may  have  sciatic  neuralgia  or  hydronephrosis,  and  even  intestinal 
obstruction  may  develop.  Death  is  often  due  to  the  presence  of  an 
echinocoecus  cyst  in  another  organ. 

Diagnosis. — The  disease  being  nearly  exclusively  limited  to  certain 
regions,  geographical  considerations  may  give  a  hint  as  to  its  exist- 
ence. Early  in  its  course  the  presence  of  one  or  more  round,  remark- 
ably smooth,  tensely  elastic  tumors  in  the  connective  tissue  of  the 
posterior  part  of  the  pelvis,  with  a  thin  homogeneous  wall,  little 
movable,  insensitive,  unconnected  with  the  uterus  or  the  ovaries,  and 
not  causing  any  local  or  general  disturbance,  makes  it  very  likely 
that  one  has  to  deal  with  one  or  more  echinocoecus  cysts  in  the  con- 
nective tissue.  The  last  point  is  the  basis  of  the  differential  diagnosis 
from  intraligamentous  ovarian  cysts,  which  very  early  become  the  source 
of  such  disturbances.  The  cervix  is  also  very  characteristic  in  hyda- 
tids,  being  situated  in  a  depression  surrounded  by  an  elastic  mass  like 
an  air-cushion. 

The  fluid  contained  in  the  cyst  is  colorless,  opalescent,  or  yellow ; 
clear  or  turbid.  It  does  not  contain  albumin  or  only  traces  of  it,  but 
succinic  acid,  leucin,  grape-sugar,  inosite,  and  sometimes  urea  and  uric 
acid.  A  single  booklet  from  the  scolices  (young  tape-worms)  or  the 
smallest  piece  of  cuticula  (the  tunica  propria  of  the  sac)  which  shows 
parallel  structureless  layers  arranged  with  the  utmost  regularity,  and 
which  is  not  affected  by  acetic  acid,  is  pathoguoraonic  of  a  hydatid.1 
If  exploratory  puncture  is  resorted  to,  it  must,  however,  be  made 
with  the  strictest  antiseptic  precautions. 

1  Garrigues,  Diagnosis  of  Ovarian  Cysts,  p.  74. 


DISEASES  OF  THE  PELVIS.  681 

A  vesicular  mole  always  forms  one  continuous  body,  and  has  cha- 
racteristic appendages,  while  the  echinococcus  often  is  multiple,  and 
has  a  smooth  surface.  Fibroma  is  harder  and  nodular. 

The  hydatidic  thrill  cannot  be  utilized  for  the  diagnosis,  as  it  cannot 
be  felt  in  pelvic  hydatids. 

Treatment. — If  the  tumor  is  confined  to  the  pelvis,  and  does  not 
cause  much  discomfort,  it  is  better  to  leave  it  alone.  But  if  it  is 
necessary  to  interfere,  it  is  best  to  make  a  large  incision  in  the  vagina. 
If  there  are  numerous  tumors,  the  internal  use  of  potassium  iodide 
and  tincture  of  kamala  (3j-3ss)  lias  been  recommended.  Electrol- 
ysis may,  perhaps,  kill  the  animal  and  cause  absorption.  A  submu- 
cous  uterine  hydatid  may  be  treated  with  ergot  in  the  hope  of  its 
becoming  pedunculated  like  a  fibroid  polypus.  If  the  tumor  rises 
into  the  abdominal  cavity,  laparotomy  should  be  performed,  the  tumor 
enucleated,  and  the  cyst- wall  of  connective  tissue  formed  around  the 
animal,  the  so-called  ectocyst,  treated  as  after  enucleation  of  a  fibroid 
(p.  499).  Often  it  is  not  possible  to  remove  the  whole  mother-cyst, 
and  then  the  edges  of  the  opening  made  in  the  cyst  should  be  stitched 
to  those  of  the  abdominal  incision  and  packed  with  iodoform  gauze. 
After  spontaneous  rupture  of  an  echinococcus  cyst  it  is  necessary  to 
dilate  the  opening  or  make  a  counter-opening. 


APPENDIX. 

I.   STERILITY. 

JUST  as  I  found  it  proper  to  begin  the  description  of  the  diseases 
of  women  by  special  chapters  on  the  two  symptoms  hemorrhage  and 
leucorrhea,  I  deem  it  advisable  for  practical  purposes  to  finish  with 
one  on  sterility,  since  it  is  a  symptom  that  often  impels  the  patient 
to  seek  medical  advice,  depends  upon  a  great  variety  of  conditions, 
and  calls  for  special  treatment,  part  of  which  has  not  been  described 
in  the  foregoing  pages. 

We  have  seen  in  the  physiological  part  of  this  work  (p.  121)  that 
fecundation  consists  in  the  union  of  the  male  and  the  female  genera- 
tive elements ;  but  many  obstacles  may  prevent  such  union  or,  if  it 
takes  place,  prevent  the  development  that  results  in  the  formation  of 
a  fetus.  The  premature  expulsion  of  the  fetus  by  abortion  or  mis- 
carriage, which  also  leads  to  childlessness,  belongs  to  the  domain  of 
obstetrics. 

By  sterility,  barrenness,  or  infecundity  we  understand  the  lack  of 
capacity  for  conception  or  impregnation.  One  marriage  out  of  every 
eight  is  childless.  It  is  commonly  believed  that  the  fault  is  always 
or  nearly  always  to  be  found  in  the  wife,  and  with  some  people  it  has 
been  deemed  a  sufficient  cause  for  repudiation ;  but  modern  investiga- 
tion has  shown  that  the  husband  is  at  fault  in  about  one  case  out  of 
every  six.1 

Sterility  in  the  Male. — Infecundity  in  man  may  be  due  to  impotence, 
or  inability  to  perform  the  sexual  act ;  to  aspermatism,  absence  of 
ejaculation ;  or  to  azoospermia  (also  called  azobspermatism  or  azoo- 
spermism),  the  condition  in  which  the  ejaculated  semen  does  not  con- 
tain any  spermatozoids,  and,  therefore,  has  no  fertilizing  power.  It 
even  seems  that  the  man  may  produce  healthy  semen  in  his  testicles, 
but  that  by  admixture  with  abnormal  secretions  during  the  passage 
through  the  vas  deferens,  the  canalis  ejaculatorius,  and  the  urethra  a 
change  takes  place,  in  consequence  of  which  the  spermatozoids  soon  die. 

The  chief  cause  of  sterility  in  the  male  is  latent  gonorrhea.  A 
man  may  have  been  free  from  gonorrhea!  discharge  for  years,  and 

1  Samuel  W.  Gross,  Impotence,  Sterility,  and  Allied  Disorders  in  the  Male  Sexual 
Organs,  Philadelphia,  1881,  p.  88. 
682 


APPENDIX.  683 

still  an  olive-pointed  bougie  may  discover  wide  strictures  in  the  mem- 
branous part  of  the  urethra,  and  bring  to  light  a  drop  of  muco-pus, 
while  at  the  same  time  spermatozoids  are  absent,  a  condition  which 
is  supposed  to  be  due  to  the  action  of  micrococci.1 

Sterility  in  the  Female. — The  female  genital  tract  being  so  much 
longer  than  that  of  the  male,  and  subject  to  such  numerous  diseases, 
it  is  quite  natural  that  the  cause  of  barren  marriages  is  found  so  much 
more  frequently  in  woman  than  in  man. 

It  should  be  borne  in  mind  that  fecundity  in  women  is  limited  to 
a  certain  period  of  their  lives.  Before  puberty  and  after  the  climac- 
teric sterility  is  normal. 

Sterility  may  be  primary  or  secondary.  It  is  primary  when  a 
woman,  in  spite  of  frequent  intercourse,  never  conceives ;  it  is  sec- 
ondary if  it  appears  after  she  has  had  one  or  a  few  children. 

The  sexual  element  (the  ovum)  may  be  absent  or  it  may  be  pre- 
vented from  contact  with  the  male  element,  the  spermatozoid,  by 
incapacity  for  copulation,  which,  again,  may  be  mechanical  or  nerv- 
ous; by  incapacity  for  conception,  which  may  be  due  to  local  tis- 
sue-changes or  constitutional  disturbances;  or  by  incapacity  for  ges- 
tation. 

1.  Absence  of  Ova. — In  chronic  oophoritis  the  ovisacs  and  ova  are 
often  diseased  and  disappear  (p.  560).2      By  the  development  of. 
cysts  and  solid  tumors  of  the  ovaries  the  ovisacs  may  disappear, 
but  the  sterility  so  common  in  these  cases  is  often  due  to  other  causes 
(p.  589). 

2.  Incapacity  for  Copulation. — Incapacity  for  copulation  may  be 
mechanical  or  nervous. 

(a)  Mechanical  incapacity  may  either  be  absolute,  as  in  cases  of  the 
absence  of  the  vulva  (p.  255),  coalescence  of  labia  (p.  258),  or  atre- 
sia  of  the  hymen  (p.  326)  or  vagina  (p.  328) ;  or  it  may  only  be 
relative,  opposing  a  more  or  less  important  obstacle  to  the  perfect 
union  of  the  sexes,  such  as  solid  or  cystic  tumors  of  the  vulva 
(pp.  275-287),  kraurosis  (p.  288),  or  cysts,  fibroids,  mucous  polypi, 
or  carcinoma  of  the  vagina  (pp.  358,  359,  361).  A  tear  of  the  peri- 
neum, allowing  the  semen  to  flow  out,  may  also  be  a  cause  of  steril- 
ity, but  is  of  comparatively  small  importance. 

(6)  Nervous  incapacity  is  connected  with  hyperesthesia  of  the  vulva 
(p.  275),  painful  urethral  caruncle  (p.  282),  and,  in  its  worst  form, 
with  vaginismus  (p.  355). 

3.  Incapacity  for  conception  may  either  be  local  or  constitutional, 
(a)  Local  incapacity  may,  again,  constitute  an  absolutely  instir- 

1  E.  Noeggerath  was  the  first  to  call  attention  to  latent  gonorrhea  in  both  sexes, 
and  its  influence  on  fertility  (Trans.  Amer.  Gyn.  $oc.,  1876,  vol.  i.  p.  268,  et  seq.). 

2  These  retrograde  processes  have  been  carefully  studied  and  delineated  by  Mary 
Dixon  Jones  (Med.  Record,  Sept.  19,  1891,  vol.  xl/p.  324). 


684  APPENDIX. 

mountable  obstacle  to  conception,  as  in  cases  of  absence  of  the  uterus 
(p.  387),  a  rudimentary  uterus  (p.  388),  atresia  of  the  genital  canal 
(pp.  326,  328,  391,  420),  or  only  a  more  or  less  serious  hindrance. 
Vaginal  catarrh  (p.  344)  may  cause  sterility  through  the  hyperacidity 
of  the  discharge,  which  kills  the  spermatozoids.  Women  with  urinary 
fistula  rarely  conceive,  partly  on  account  of  mutual  disinclination  to 
copulation,  partly  in  consequence  of  concomitant  diseased  conditions. 

Most  of  the  malformations  and  diseases  of  the  uterus,  tubes,  ovaries, 
and  pelvis  are  accompanied  by  or  have  a  tendency  to  produce  sterility, 
such  as  the  fetal,  infantile,  or  pubescent  uterus  (pp.  392,  393),  congen- 
ital or  acquired  displacements  of  the  uterus  (pp.  394,  433-466), 
elongation  and  hypertrophy  of  the  cervix  (pp.  381,  411),  stenosis 
of*  the  cervical  canal  (pp.  394,  421),  superiii volution  of  the  uterus 
(p.  431),  chronic  endometritis  (p.  407),  or  a  polypus  obstructing  the 
cervix  or  the  tube  (p.  467).  Women  with  sessile  fibroids  are,  as  a 
rule,  also  sterile,  and  their  barrenness  is  probably  due  more  to  the 
accompanying  catarrh  than  to  the  mechanical  obstruction.  In  car- 
cinoma of  the  cervix  (p.  507)  infecundity  may  be  due  to  the  consti- 
tutional disturbance  as  well  as  to  mechanical  obstacles. 

In  regard  to  the  Fallopian  tubes  congenital  contortions  (p.  524)  or 
acquired  displacement  (p.  546)  may  oppose  an  impediment  to  the  free 
movement  of  the  ovum  or  the  spermatozoids.  They  may  be  imper- 
vious (p.  524),  or  their  inflammation  (p.  528)  or  neoplasms  (p.  546) 
may  prevent  conception. 

The  surface  of  the  ovaries  may  be  so  covered  with  inflammatory 
products  that  the  ovum  cannot  escape  (p.  560). 

The  presence  of  hydatids  in  the  pelvis  (p.  678)  or  a  mole  in  the 
uterus,  uterine  hemorrhage,  or  leucorrhea  from  whatever  cause,  may 
render  the  woman  sterile. 

(6)  Constitutional  Incapacity. — Anemic  women  are  less  likely  to 
conceive  than  healthy  women.  Great  obesity  is  quite  frequently 
accompanied  by  barrenness.  Tuberculosis,  syphilis,  and  cancer, 
all  diminish  fecundity.  The  same  applies  to  masturbation  (p.  300) 
and  to  too  frequent  or  violent  coition,  as  in  prostitutes.  It  is  not 
unlikely  that  in  the  last-named"  condition  impregnation  often  takes 
place,  but  that  the  ovum  is  expelled  at  so  early  a  date  that  not  even 
menstruation  is  interrupted. 

Bisulphide  of  carbon  seems  to  exercise  a  highly  deleterious  influence 
on  procreation  in  both  sexes  among  those  whose  calling  exposes  them 
to  its  influence.  It  is  used  much  in  the  arts  as  a  solvent  for  vegetable 
oil  and  rubber.  In  the  male  it  lessens  the  desire  and  the  power  for 
sexual  intercourse.  In  females  conception  is  rare,  and,  when  it  takes 
place,  they  almost  always  abort. 

4.  Incapacity  for  Gestation. — This  condition  is  often  combined  with 
the  incapacity  for  conception,  barrenness  alternating  with  abortions 


APPENDIX.  685 

and  miscarriages.  An  inflamed  endometrium,  for  instance,  offers  a 
poor  soil  for  the  growth  of  an  ovum,  so  that  fetal  development  is 
likely  to  be  arrested,  the  pregnancy  ending  in  a  miscarriage ;  but  the 
ovum  may  also  be  washed  out  by  hemorrhagic  and  leucorrheal  dis- 
charges, before  it  ever  becomes  imbedded,  and  perhaps  before  it  is 
fertilized. 

Diagnosis. — 'Fecundity  depending  upon  the  union  of  elements 
derived  from  two  individuals,  it  is  proper  in  a  case  of  sterility  to  look 
for  the  cause  or  causes  in  both  persons  concerned ;  but,  unfortunately, 
it  happens  that  the  husband,  while  he  is  quite  willing  to  submit  his 
wife  not  only  to  the  most  searching  physical  examination,  but  even  to 
operative  procedures,  absolutely  refuses  to  be  examined  himself. 
There  is,  sometimes,  a  lingering  doubt  in  his  mind  that  the  fault 
might  be  on  his  side,  and  he  dreads  above  all  to  acquire  this  certainty, 
or  at  least  to  let  his  wife  know  it.  If  he  is  willing  to  give  the  neces- 
sary information,  he  should,  first  of  all,  be  questioned  in  regard  to 
copulation,  ejaculation,  syphilis,  and  gonorrhea.  The  proper  position 
of  his  meatus  urinarius  should  be  ascertained.  His  urethra  should 
be  carefully  examined  with  a  bougie-a-boule  or  an  endoscope  as  to 
caliber  and  small  pus-secreting  surfaces  lurking  behind  strictures. 
Finally,  his  semen  must  be  examined  microscopically.  The  proper 
way  of  obtaining  it  unmixed  with  foreign  substances  is  to  let  him 
have  intercourse  with  his  wife,  using  a  condom.  Immediately  after 
copulation  this  bag  with  its  contents  is  thrown  into  a  wide-mouthed 
bottle  and  brought  to  the  physician,  who  examines  it  without  delay. 
If  the  man's  semen  is  full  of  living  spermatozoids,  the  examination 
may  be  extended  to  the  woman,  in  order  to  find  out  if  there  is  any 
discharge  in  the  vagina  that  kills  the  spermatozoids.  For  this  pur- 
pose the  husband  should  be  allowed  to  have  normal  intercourse  with 
his  wife,  and  shortly  after  the  act  a  little  semen  should  be  removed 
from  the  posterior  vault  of  the  vagina  with  a  Simon's  spoon  and 
examined  microscopically.  Often  it  suffices,  however,  to  examine 
the  woman  without  having  recourse  to  this  somewhat  repugnant 
procedure. 

In  examining  the  woman  the  physician  will  bear  in  mind  all  the 
malformations  and  diseases  just  enumerated  that  may  entail  sterility. 
The  vaginal  secretion  should  be  tested  with  litmus-paper.  It  is  nor- 
mally acid,  but  it  may  be  so  to  such  a  degree  that  it  kills  the  sperma- 
tozoids. It  should  also  be  examined  microscopically  for  pus-corpus- 
cles, the  presence  of  which  always  shows  inflammation.  The  utero- 
tubal  mucus  is  obtained  by  introducing  a  speculum  and  taking  the 
mucus  directly  out  of  the  cervical  canal.  This  is  normally  alkaline, 
and  any  acid  fluid  is  deleterious  to  the  spermatozoids. 

Treatment. — In  regard  to  the  treatment  of  the  man  the  reader  is 
referred  to  works  on  venereal  diseases. 


686  APPENDIX. 

Ofteii  a  certain  mutual  adaptation  seems  to  be  necessary.  Nothing 
is  more  common  than  that  impregnation  does  not  take  place  immedi- 
ately upon  entering  upon  marital  relations.  Many  months  may  even 
elapse  before  it  occurs  between  perfectly  healthy  individuals.  A  little 
patience  is,  therefore,  always  to  be  recommended.  But,  on  the  other 
hand,  accurate  statistics  have  shown  that  three-fourths  of  married 
women  get  a  child  in  the  course  of  the  first  year  of  their  marriage, 
and  that  if  three  years  elapse  without  offspring  the  chances  of  hav- 
ing children  become  very  small.  As  a  practical  rule,  we  may  say 
that  if  a  woman  does  not  conceive  during  the  first  year  of  her 
marriage,  and  wishes  to  become  a  mother,  she  had  better  seek  med- 
ical advice. 

The  entrance  of  the  semen  into  the  uterus  may  be  favored  by  rais- 
ing the  pelvis  during  copulation  or  by  coition  modo  brutorum.  Trav- 
eling has  a  marked  influence,  which  may  be  due  to  climatic  influ- 
ences, change  of  diet,  or,  more  likely,  the  diversity  of  couches. 

The  causes  of  sterility  in  the  female  being  so  manifold  and  com- 
prising most  of  the  malformations  and  diseases  treated  of  in  this 
work,  the  treatment  will,  of  course,  also  vary  much,  the  general  rule 
being  to  remove,  if  possible,  whatever  cause  or  causes  we  may  find  by 
the  means  indicated  in  the  preceding  chapters. 

Anemia  is  treated  with  iron,  manganese,  strychnine,  cod-liver  oil, 
terraline,  and  a  diet  in  which  albuminoids  preponderate,  and  into 
which  enters  the  use  of  milk,  beer,  or  wine.  Adipose  tissue  is 
reduced  by  iodine,  fucus  marina,  exercise,  massage,  Turkish  baths, 
and  a  diet  from  which  sweets  and  cereals  are  nearly  excluded,  and 
in  which  liquids  are  limited  as  much  as  possible.1 

A  too  small  uterus  may  sometimes  be  enlarged  by  the  galvanic 
current. 

Many  different  operations  may  be  called  for  in  order  to  remedy 
sterility.  The  labia  may  have  to  be  separated  ;  a  resistant  hymen 
removed  ;  a  painful  caruncle  destroyed  ;  a  vagina  made ;  or  an  elon- 
gated cervix  amputated.  The  cervical  canal  may  require  dilata- 
tion, which  may  be  kept  up  by  the  use  of  Outerbridge's  permanent 
dilator  (p.  184) ;  a  polypus  may  have  to  be  cut  off;  a  spongy  endo- 
metriuin  may  need  curetting,  etc.  Sometimes  the  operation  required 
is  not  one  of  division,  but  of  union,  as  when  a  torn  perineum  and 
vagina  are  repaired  or  trachelorrhaphy  is  performed.  A  torn  cer- 
vix would  seem  to  favor  impregnation  by  offering  freer  entrance  to 

1  Such  a  diet  should  be  composed  of  beef,  mutton,  veal,  pork,  game,  poultry, 
eggs,  fish,  lobsters,  crabs,  shrimps,  oysters,  clams,  scollops,  muscles,  cheese,  green 
vegetables,  lettuce  salad,  and  a  small  amount  of  juicy  fruit,  with  a  pint  of  claret  or 
Moselle  wine,  a  cup  of  black  coffee,  a  cup  of  tea  without  milk,  and  four  ounces  of 
bread  per  day.  Butter  and  other  fats  are  harmless.  Forbidden,  on  the  other  hand, 
are  soups,  water,  milk,  beer,  potatoes,  beets,  puddings,  pies,  and  other  sweet  dishes, 
as  well  as  bananas. 


APPENDIX.  687 

the  interior  of  the  womb ;  but,  on  the  other  hand,  the  endometritis 
following  the  tear  is  a  barrier  to  conception ;  and,  as  a  matter  of 
fact,  I  may  state  that  I  have  repeatedly  removed  sterility  by  this 
operation. 

Laparotomy  or  colpotorny  will  hardly  be  undertaken  for  sterility 
alone,  since  it  would  risk  an  existing  life  in  the  uncertain  hope  of 
rendering  another  possible ;  but  when  it  is  undertaken  for  legitimate 
causes,  it  may  perhaps  even  cure  sterility,  if  the  operator  finds  it  pos- 
sible to  leave  one  or  both  ovaries  and  render  the  tubes  permeable 
(p.  533). 

When  all  other  means  fail,  or  no  cause  for  the  sterility  can  be 
found,  or  the  woman  refuses  any  kind  of  cutting  operation,  we  may 
yet  try  artificial  impregnation.  Since  the  fundamental  condition  of 
fecundity  is  the  union  of  a  spermatozoid  and  an  ovum  (p.  121),  since 
in  most  cases  it  is  an  easy  matter  to  introduce  semen  all  the  way  up 
to  the  fundus  of  the  uterus,  and  since  artificial  fertilization  is  used  on 
a  large  scale  in  pisciculture,  one  would  think  that  artificial  impregna- 
tion of  a  woman  could  likewise  be  performed  without  difficulty.  But 
it  is  not  so.  It  has  been  tried  many  times,  but  has  nearly  always 
proved  a  failure. 

The  operation  is  very  simple.  The  semen  of  the  husband  having 
been  found  normal,  and  especially  after  ascertaining  that  it  does  not 
contain  pus-corpuscles,  he  has  intercourse  with  his  wife,  using  a  con- 
dom. This  he  brings  to  the  physician  waiting  in  another  room. 
The  latter  has  in  readiness  an  intra-uterine  syringe  (p.  172),  properly 
disinfected  and  kept  warm.  He  sucks  a  small  amount  of  semen  up 
with  the  syringe,  exposes  the  os  uteri  with  a  speculum,  wipes  it  off 
with  cotton  dipped  in  some  antiseptic  fluid,  introduces  the  nozzle  up 
to  the  fundus,  and  expresses  a  few  drops  slowly  into  the  interior  of 
the  womb.  The  woman  should  stay  in  bed  on  her  back,  and  if  she 
feels  any  pain  an  ice-bag  should  be  applied  to  the  hypogastric  region. 
The  most  favorable  time  for  performing  the  operation  is  shortly 
before  menstruation  is  expected,  and  the  next  best  period  is  imme- 
diately after  the  catamenia  (p.  119).  It  may,  of  course,  be  repeated 
during  several  months,  if  the  first  attempt  does  not  succeed. 


II.    LACK  OF  ORGASM. 


A  CONDITION  for  which  we  are  not  infrequently  consulted  is  lack 
of  the  normal  feeling  of  the  highest  sexual  excitement  called  orgasm 
(p.  121).  Both  the  husband  and  the  wife  deplore  a  defect  which 
deprives  the  marital  relation  of  its  highest  physical  satisfaction,  and 
some  knowing  women,  in  order  to  retain  their  husbands'  affection, 


688  APPENDIX. 

simulate  a  state  which  does  not  exist  in  reality.  Some  women  have 
never  felt  this  sensation.  With  them  the  fault  is  congenital,  and  is 
probably  due  to  some  imperfection  in  the  central  nervous  system. 
Others  know  the  sensation  from  previous  experience,  but  have  lost 
the  faculty  of  feeling  it.  Some  feel  it  dreaming,  but  never  during 
intercourse.  The  lack  of  orgasm,  both  the  primary  and  the  second- 
ary, may  be  found  in  otherwise  perfectly  healthy  women,  and  is  not 
a  barrier  to  conception. 

Primary  lack  of  orgasm  is  incurable,  and  it  is  very  doubtful  if  the 
acquired  form  allows  us  to  give  a  better  prognosis.  In  my  own 
practice  I  have  constantly  failed  with  the  use  of  tonics,  the  galvanic 
current,  and  aphrodisiac  drugs,  such  as  damiana,  phosphorus,  and 
cantharides. 


III.    INTESTINAL  SURGERY. 

IN  operations  on  the  internal  genitals,  especially  ovariotomy  and 
salpingo-oophorectomy,  the  gynecologist  is  sometimes  incidentally 
forced  to  operate  on  the  intestine.  A  short  description  of  the  chief 
operations  of  this  kind,  such  as  resection,  lateral  anastomosis,  end-to- 
end  approximation  by  artificial  invagination,  the  use  of  the  intestinal 
button,  and  the  removal  of  the  appendix  vermiformis,  may,  therefore, 
not  be  out  of  place  here. 

A.  Resection  of  Intestine. — The  bowels  are  squeezed  empty  for  five 
or  six  inches  in  either  direction  from  the  part  to  be  removed  and 
compressed  with  special  forceps  (Murphy),  a  safety-pin  and  sponge 
(Maunsell),  a  strip  of  gauze,  or  an  elastic  ligature  carried  through  a 
hole  in  the  mesentery  and  tied  round  the  intestine.     The  intestine  is 
cut  across,  and  the  mesentery  is  treated  in  one  of  two  ways,  either  by 
excision  or  by  folding.     Either  a  wedge  is  cut  out,  the  base  of  which 
corresponds  to  the  piece  of  intestine  to  be  removed,  and  the  apex  to 
the  root  of  the  mesentery ;  next,  the  two  edges  are  stitched  together, 
according  to  the  thickness  of  the  mesentery,  by  a  single  running  su- 
ture or  by  a  double,  stitching  each  layer  of  the  mesentery  separately. 
Or  the  mesentery  is  cut  along  the  piece  of  intestine  to  be  removed, 
using  blunt  scissors,  and  separating  the  peritoneum  as  much  as  pos- 
sible from  the  intestine  before  cutting  it.     When  the  ends  of  the 
intestine  have  been  brought  together,  the  edge  of  the  mesentery  is 
doubled  up  and  stitched  together,  and  the  flap  formed  in  this  way  is 
itself  fastened  to  the  remainder  of  the  mesentery  with  a  few  stitches. 

B.  Lateral  Anastomosis.1 — A  part  of  the  intestine  having  been 
resected,  each  end  of  the  inverted  gut  is  closed  with  a  double  row 
of  continuous  sutures  with  fine  black  silk.     Next,  the  mesentery  is 

1  Eobert  Abbe,  Med.  Record,  April  2,  1892,  vol.  xli.  p.  365. 


APPENDIX.  689 

divided  sufficiently  to  draw  the  ends  of  the  severed  gut  past  each 
other,  so  as  to  make  them  overlap  for  six  inches  (Fig.  332).  In  this 
position  they  are  sutured  together  by  two  rows  of  Lembert  sutures,  a 
quarter  of  an  inch  apart,  carrying  a  running  suture  of  finest  black 
embroidery  silk  with  a  cambric  needle.  Half  a  dozen  such  needles 
should  be  threaded  with  silk  threads  twenty-four  inches  long,  and 
the  silk  tied  to  the  eye  of  the  needle  with  a  simple  knot,  leaving  a 
short  end  two  inches  long.  The  lines  of  sutures  are  made  about  five 
inches  long,  and  the  two  needles  are  left  on  their  silk  threads.  Next, 
an  incision  four  inches  long  is  made  with  scissors  in  both  ends  of 
intestine,  a  quarter  of  an  inch  from  the  nearest  of  the  two  sutures, 
applying  hemostatic  forceps  to  bleeding  points.  Next,  another  over- 
hand suture  is  started  at  one  end  of  the  incision,  uniting  the  two 
edges  nearest  the  previous  sutures,  and  penetrating  both  serous  and 
mucous  coats,  which  arrests  hemorrhage.  This  suture  is  then  contin- 
ued round  each  of  the  two  free  edges  separately.  Finally,  the  needles 

FIG.  332.  FIG.  333. 


Maunsell's  Intestinal  Imagination:  a, 
a,  temporary  sutures ;  b,  needle  carry- 
Abbe's  Intestinal  Anastomosis.  ing  horsehair. 

of  the  first  two  sutures  are  taken  up  one  after  the  other,  and  used  to 
complete  the  double  row  of  Lembert  sutures  around  the  opening 
made  in  the  intestine. 

There  is  no  doubt  of  the  excellence  of  this  operation,  but  in  order 
to  be  performed  within  a  reasonable  time  it  demands  a  hand  used  to 
that  kind  of  work. 

C.  End-to-end  Approximation  by  Artificial  Imagination.1-  Two 
temporary  sutures  are  placed,  one  at  the  mesentery  and  one  just  oppo- 
site, carrying  them  through  all  three  coats  of  the  two  ends  of  the 
severed  intestine.  Next,  a  longitudinal  hole,  one  and  a  half  inches 
long,  is  cut  in  the  larger  part  of  the  intestine  one  inch  from  the  end, 
and  the  two  temporary  sutures  are  hauled  out  through  this  opening, 
carrying  the  end  of  the  intestine  after  them.  Ten  horsehair  or  s 
worm-gut  sutures  are  now  carried  through  both  walls  of  intestine 
(Fig.  333),  picked  up  in  the  middle,  and  cut,  thus  forming  twenty 
H.  Widenham  Maunsell,  Amer.  Jour.  Med.  Sci,  March,  1892,  p.  245. 


i 

44 


690 


APPENDIX. 


sutures,  which  then  are  tied.  The  temporary  sutures  are  removed. 
Next,  the  invaginated  portion  of  intestine  is  hauled  back,  and  the 
longitudinal  opening  closed  with  a  running  silk  suture  through  the 
serous  and  muscular  coats  only. 

This  is  a  reliable  operation,  and  not  particularly  difficult. 
D.  Murphy's l  Button  (Fig.  334). — Through  the  ingenious  device 
of  Dr.  Murphy  of  Chicago  we  are  now  enabled  to  do  away  with 
enterorrhaphy  altogether.  It  consists  of  a 
set  of  four  button-like  contrivances,  one  of 
which  is  chosen  according  to  the  diiferent 
sizes  of  the  intestines  to  be  united.  Each 
button  consists  of  a  male  and  a  female  half. 
The  female  half,  again,  is  composed  of  a  cen- 
tral cylinder  that  has  a  shallow  screw  thread 
on  its  inner  surface  and  a  wide  bowl-shaped 
flange  with  five  large  holes  for  the  passage 
of  gas.  The  male  half  is  composed  of  a 
similar  central  cylinder  with  two  small  fe- 
nestrae,  through  which  pass  two  small  pro- 
tuberances fastened  with  springs  to  the  in- 
side of  the  cylinder.  The  tube  has  a  similar 
perforated  bowl-shaped  flange  to  that  of  the 
female  half,  but  besides  that  it  has  a  mov- 
able ring  surrounding  the  central  cylinder 
and  fastened  to  the  bottom  of  the  bowl  with 
a  spiral  spring.  This  male  half  fits  in  the 
female,  the  lateral  prominences  adapt  them- 
selves to  the  screw  thread,  and  the  ring  ex- 
ercises a  pressure  on  the  rim  of  the  intestine 
comprised  between  the  two  halves  of  the 
button,  producing  constant  approximation 
and  ultimate  absorption,  while  adhesive  in- 
flammation closes  the  line  of  union  between 
the  two  pieces  of  intestine.  When  this  pro- 
cess is  finished,  the  button  is  carried  down 
through  the  intestine  and  expelled  through  the  anus.  There  is  a 
linear  cicatrice,  and  the  bowel  retains  an  opening  as  large  as  that  of 
the  button  used. 

The  Murphy  button  can  be  used  both  for  lateral  anastomosis  and 
for  end-to-end  adaptation.  For  lateral  anastomosis  the  ends  of  the  in- 
testine are  closed  with  a  double  row  of  Lembert  sutures,  as  in  Abbe's 
operation.  A  needle  with  a  silk  thread,  fifteen  inches  long,  is  inserted 
in  the  bowel  opposite  the  mesentery,  and  a  stitch  taken  longitudinally 

1  John  B.  Murphy  of  Chicago,  111.,  North  American  Practitioner,  Nov.  and 
1892 ;  New  York  Med.  Record,  May  and  June,  1894. 


Murphy's  Intestinal  But- 
ton (enlarged) :  A,  open ;  B, 
closed. 


APPENDIX. 


691 


Fio.  335. 


through  the  entire  wall  of  the  gut  one-third  the  length  of  the  incis- 
ion to  be  made.  The  needle  is  again  inserted  one-third  the  length  of 
the  future  incision  from  its  outlet,  in  a  line  with  the  first.  A  loop 
of  the  silk,  three  inches  long,  is  held  here,  and  the  needle  is  again  in- 
serted, making  two  stitches  parallel  to  the  first  two,  a  quarter  of  an 
inch  from  them  and  going  in  the  reverse  direction.  This  forms  the 
running  thread,  which  when  tightened  draws  the  incised  edge  of  the 
gat  within  the  cup  of  the  button.  A  similar  running  thread  is  placed 
on  the  other  end  of  the  gut.  A  hole  is  cut  inside  of  the  suture,  which 
hole  should  not  be  longer  than  two-thirds  of  the  length  of  the  diam- 
eter of  the  button  used.  The  ligatures  are  tightened  round  the  cen- 
tral cylinders,  the  two  halves  of  the  button  are  pressed  together,  and 
the  intestine  dropped  into  the  abdominal  cavity.  In  inserting  the 
male  half  into  the  intestine  the  movable 
ring  should  be  pressed  down  to  a  level  with 
the  flange,  and  this  should  be  grasped  with 
a  forceps  and  held  while  the  first  half  of  the 
knot  is  being  made.  When  the  gut  is  drawn 
close  about  the  central  cylinder,  the  forceps 
is  changed  to  the  edge  of  this  cylinder  and 
the  knot  is  completed. 

In  the  end-to-end  adaptation  each  half 
of  the  button  is  inserted  in  one  end,  but 
before  so  doing  a  running  suture  is  intro- 
duced in  such  a  way  as  to  prevent  the  ever- 
sion  of  the  mucous  membrane  and  insuring 
the  overlapping  of  the  mesentery.  This  is 
obtained  by  beginning  at  a  opposite  the  mes- 
entery, using  a  top  stitch  along  the  incised 
edge,  taking  a  return  over-stitch  (6)  at  the 
mesentery,  and  continuing  the  top  stitch  on 
the  opposite  side,  back  to  the  starting-point 
(Fig.  335). 

This  method  is  the  simplest  and  most  ex- 
peditious of  all. 

E.  Ecphyadectomy,  or  removal  of  the  ap- 
pendix vermiformis.  If  in  performing  lap- 
arotomy  the  appendix  vermiformis  is  found 
diseased,  it  is  proper  to  remove  it.  A  con- 
tinuous Lembert  suture  of  silk  is  made  to 
surround  the  appendix,  running  like  a  purse- 
string  in  the  superficial  layers  of  the  cecum 
one-fourth  of  an  inch  from  the  appendix. 
The  suture  is  not  tightened,  but  only  half  of  a  surgeon's  knot  i? 
made.  Next,  the  appendix  is  divided,  leaving  a  stump  at  least  half 


Manner  of  Inserting  Running 
Su'nre  in  End  of  Intestine 
(Murphy):  a, starting-point; 
b,  return  over-stitch  at  mes- 
entery. 


692  APPENDIX. 

an  inch  long.  This  stump  is  stretched  by  introducing  a  fine  pair  of 
forceps  through  it  into  the  cecura  and  opening  it  gently.  With 
another  pair  of  fine  mouse-toothed  forceps  the  stump  is  invaginated 
and  carried  into  the  interior  of  the  cecum.  And,  finally,  the  suture 
around  its  base  is  tightened  over  it.1 

1  Dawbarn,  Inteniatiorud  Journal  of  Surgery,  1895,  vol.  viii.,  No.  8. 


INDEX. 


A. 

Abbe,  intestinal  anastomosis,  688 
Abdominal  hysterectomy,  431,  493,  520 

regions,  113 

section,  609 

wall,  adherent  to  ovarian  cyst,  616 
Abortion,  cause  of  disease,  130 
Abortionist.  395 
Abscess — 

after  ovariotomy,  deep,  633 

mural,  633 

of  vulvovaginal  gland,  290 

ovarian,  557 

pelvic,  665 
Accessory  abdominal  ostia  of  Fallopian 

tube,  524 

A.  C.  E.  mixture,  206 
Acid — 

carbolic,  181,  188,  205,  272,  293 

hydrocyanic,  211,  269 

sclerotinic,  480 
Adenoma — 

benign,  408,  467 

malignant,  408,  467 

uteri,  467 
Adhesions — 

ovarian,  553,  585,  617 

severance  of  uterine,  453 

tearing  of,  450 
After-treatment,  223 

after  ovariotomy,  615 

complications  during,  631 
Air-pressure,  445 
Ala  vespertilionis,  26,  64 
Albuginea,  27,  67 
Alcohol  for  disinfection,  199 
Alexander's  operation,  448 
Alimentation,  rectal,  225 
Allantois,  32 
Allis,  inhaler,  207 
Allongement  of  polypus,  479 
Aloes,  225 

Ameboid  bodies,  578 
Amenorrhea,  238 

proper,  239 
Ampulla  of  Fallopian  tube,  63 


Ampulla — 

rectal,  85 
Amputation  — 

of  cervix,  418,  428,  429,  442 

of  inverted  uterus,  465 

supravaginal,    of   uterus,    496.      (See 

Hysterectomy. ) 
Anal  region,  99 
Anatomy,  35 
Anesthesia,  206 

causing   paralysis,  numbness  or  pain, 
198 

in  Trendelenburg's  position,  209 
Aneurysm  of  uterine  artery,  643 
Angioma — 

of  uterus,  468 

of  vulva,  282 
Anodynes,  226 
Anteflexion,  394,  438 

acquired,  439 

cervical,  '438 

cervicocorporeal,  438 

congenital,  439 

corporeal,  438 

developmental,  439 

Dudley's  operation  for,  442 

irreducible,  438 

reducible,  438 

salpingo-oophorectomy,  442 

Sims's  operation  for,  441 
Anteposition,  394 
Anterior  commissure,  36 
Anteversion,  433 

operations  for,  437 
Antiblennorrhagic  drugs,  348 
Antidysmenorrheal  drugs,  243 
Antipyretics,  228 
Antisepsis,  199 
Antiseptic — 

fluids,  205 

material,  199 
Anna,  preternatural,  381 
Aperients,  225 
Apostoli,  electrode,  230,  231 

method,  233 
Applications,  170 
Applicator,  170 

693 


694 


INDEX. 


Arbor  vitae,  49 
Arch,  tendinous,  94 
Aristol,  205 
Arnold,  sterilizer,  199 
Arteries — 
helicine,  60 
ligation  of  internal  pudic,  .183 

of  uterine,  182 
of  perineal  region,  105 
of  uterus,  60 

Artificial  impregnation,  687 
Ascites,  585,  594,  599,  629 
Asepsis,  199 
Ashton,  speculum,  150 
Aspermatism,  682 
Aspiration,  159,  188 
exploratory,  159,  595 
through  vaginal  vault,  533,  595 
Aspirator,  159 
Dieulafoy's,  159 
Emmet's,  159 
Potain's,  159 
Assistants,  195 
Asthenopia,  134,  409 
Atresia — 
acquired,  of  uterus,  420 

of  vagina,  329 
ani  vaginalis,  333 

vestibularis,  333  , 

case  of,  331 
hymenalis,  326 
of  urethra,  372 
of  uterus,  391,  420 
of  vagina,  328 
acquired,  329 

combined  with  double  vagina,  333 
complete,  328,  333 
congenital,  329 
incomplete,  328 
Atrophy  of  uterus — 
acquired,  431 
puerperal,  431 
senile,  431 
Atropine  injected  subcutaneously  before 

anesthetizing,  197 
Auscultation,  158 
Aveling,  repositor,  464 
Azoospermatisrn,  682 
Azoospermia,  682 
Azoospermism,  682 

B. 

Bacilli,  171 

Ballooning,  146 

Bandl,  operation  for  ureterovaginal  fistula, 

373 

Bardenheuer,  hysterectomy,  491 
Barnes,  ointment-carrier,  171 


Barnes,  operation  for  inversion,  465 

replacement  of  inverted  uterus,  464 
Barton,  Rhea.   operation  for   rectolabial 

fistula,  382 
Base  of  bladder,  78 
Baths,  187 

general,  187 

Russian,  187 

sea-,  188 

sheet-,  188 

shower-,  188 

sitz-,  187 

sponge-,  188 

steam-,  187 

towel-,  188 

Turkish,  187 
Bath-speculum,  187 
Battey's  operation,  535 
Bed,  194 
Bed-pan,  171 
Belladonna,  269,  413 
Belt,  abdominal,  190 
Bern  ays,  uterotractor,  518 
Bichloride  of  mercury — 

for  parenchymatous  injection,  51& 
internally,  226 
standard  solution,  205 
Bimanual  examination,  141 

replacement  of  uterus,  445 
Bipolar  electrodes,  229 
Bismuth,  225 
Bisulphide  of  carbon,  684 
Bladder- 
adherent   to  tumors,  494,  616 

anatomy,  77 

catheterization,  39,  161 

distention,  602 

function,  81 

irrigator,  175 

irritable,  409,  413 
Blasius,  operation  for  fistula,  369 
Blind  canals  in  vagina,  333 
Blister,  188 
Bloodletting,  186 

Blood-pressure  increased  before  menstrua- 
tion, 117 

Bode,  vaginal  shortening  of  round  liga- 
ments, 453 
Bodies,  ameboid,  578 
Body,  perineal,  104 

of  womb,  47 
Boldt,  table,  195 
Bougies  with  iodoform,  406 
Bozeman,  button,  368 

operation  for  fistula,  368 

scissors,  479 

speculum,  368 

table,  368 

urinal,  375 


INDEX. 


695 


Brandt,  Thure,  911 
cure  for  prolapse,  456 
cure  for  retronexion,  450 
Braun,  syringe,  172 
Breisky,  pessary,  456 
Brewer,  speculum,  144 
Broad  ligament — 
cysts  of,  645 

diseases  of,  644  t 

during  pregnancy,  57 
solid  tumor,  648 
varicocele,  644 
Broca's  pouch,  37 
Bubo,  293 

Budd,  applicator,  170 
Bureau,     operation     for     fecal     fistula, 

384 

Burning  sensation  in  genitals  and  abdo- 
men, 274 

Burrage,  speculum,  150 
Buttle,  scarificator,  186 
Button,  Bozeman's,  368 

Murphy's,  690 
Byrne,  inversion,  465 
carcinoma  uteri,  516,  517 

C. 

Calcification — 

of  corpus  luteum,  561 

of  ovarian  cyst,  586 

of  uterine  fibroid,  474 
Calculus  due  to  suture,  371 
Camphor — 

emulsion,  351 

in  collapse,  210 
Canal — 

anal,  84 

Gartner's,  20,  358 

of  Nuck,  37,  59,  643 
hematocele  of,  263 
Canals,  blind,  in  vagina,  333 
Cancer — 

carried  through  lymph-vessels,  639 

definition,  503 

of  Fallopian  tube,  547 

of  peritoneum,  600 

of   vulva,  283.      (See  Carcinoma    and 

/Sarcoma.) 
Cancer-cells  in  ascitic  fluid  accompanying 

malignant  tumors,  513 
Capsule  of  fibroid  tumors,  469 
Carbon  bisulphide,  68 
Carcinoma — 

in  negro  race,  509 

not  transmissible  by  coition,  511 

of  body  of  uterus,  508 

of  cervix,  508 

of  Fallopian  tube,  547 


Carcinoma — 

of  ovarian  cyst,  576,  586 

of  ovary,  635 

of  pelvis,  678 

of  uterus,  507 

of  vagina,  361 

of  vaginal  portion,  507 

of  vulva,  283 
Caruncle,  urethral,  282 
Carunculffi  myrtiformes,  47 
Catarnenia,  115 
Cataphoresis,  233 
Catarrh — 

of  tite/us,  410 

of  vagina,  344 
Catgut,  202 

buried,  314 

chromicized,  204 
Catheter — 

double-current,  175 

self-retaining,  Petzer's,  486 

Sims' s,  367 
Catheterizatiou — 

of  bladder,  39,  161 

of  Fallopian  tube,  533 

of  ureter,  165 

Cauliflower  excrescence,  508 
Cauterization,  182 

galvanochemical,  233,  234 

galvanothermal,  237 

hemostatic,  182,  628 

of  fistula,  365,  382 
Cautery-clamp,  612 
Cavity—- 
of uterus,  49 

pelviperitoneal,  94 
Celibacy — 

in  relation  to  disease,  129 

to  uterine  fibroid,  474 
"  Celiotomy,"  609 
Cells,  proliferating,  578 
Cellulitis,  596 

anterior,  672 

chronic  atrophic,  674 

pelvic,  669 

posterior,  672 
Cervical  canal,  49 

carcinoma,  508 

ganglion,  62 

speculum,  150 

stenosis,  394 
Cervicitis,  404 
Cervix,  47 

amputation,  418,  428,  429,  444 

cone-mantle-shaped  excision,  419 

congenital  cleft,  398 

conical.  421 

cysts,  413,  467 

discission  of  posterior  lip,  441 


696 


INDEX. 


Cervix — 

elongated,  394,  425 

funnel-shaped  excision,  427 

high  amputation,  428,  429 

laceration,  396 

single-flap  excision,  420 

stenosis,  394,  421 

supravaginal  amputation,  428,  429 

ulcers,  424 

wedge-shaped  excision,  418 

for  retroflexiou,  448 
Chain-ligature,  625 
Chancre,  293 

hard,  293,  424 

mixed,  294 

soft,  291 
Chancroid,  291,  424 

chronic,  285,  292 
Change  of  life,  123 
Charts,  158 
Chian  turpentine,  515 
Childbirth,  cause  of  disease,  130 
Chloral  hydrate,  269 
Chloride  of  zinc,  170 

for  cauterizing  carcinoma  of   uterus, 

514 
Chloroform,  208 

embrocation,  226 

-mask,  208 
Cholesterin,  579 
Cicatrices  in  vagina,  353 
Circular  artery,  60 
Cirrhosis  of  ovary,  558 
Clamp — 

compared  with  ligature,  488 

Kceberte's,  184 

method  for  hysterectomy,  483 
Cleanliness,  140 

a  cure  for  fistula,  365,  382 
Cleisis,  378 
Cleveland,  ligature-carrier,  217 

suture,  319 

table,  195 
Climacteric,  123 

treatment,  125 
Clitoridectomy,  292,  300 
Clitoris,  abnormal,  256 

absent,  256 

amputation,  292,  300 

anatomy,  37 

development,  34 

enchondroma,  281 

function,  39 

horn,  282 
Cloaca,  32 

persistent,  333 
Cloacal  opening,  33 
Closure  of  uterus,  420 
Clover's  crutch,  197 


Clysters,  174 
Coalescence  of  labia,  258 
Cobbler's  stitch,  614,  627 
Cocaine,  209 

bougies,  356 
Coccygectoiny,  324 
Coccygodynia,  333 
Coccyx — 

anatomy,  325 

extirpation,  324 

Coe,  improvement  on  Lefort's  operation, 
458 

preventive  excision  of  cervix,  513 
Coffee  against  vomiting,  210 
Coil,  187 
Coition — 

during  menstruation,  130 

modo  brutorum,  686 
Cold,  187 

Colica  scortorum,  529 
Collapse,  207,  210,  501 
Collector,  232 
Colpeurynter,  464,  535 
Colpitis,  343 
Colpocleisis,  378 
Colpohyperplasia  cystica,  349 
Colpoperineorrhaphy,  311 
Colporrhaphy — 

anterior,  336 

bilateral,  338 

lateral,  338 

median,  336,  337 

posterior,  340 
Colpotomy,  533 

anterior,  450,  484,  487 

posterior,  484,  487,  666 
Columns — 

of  Morgagni,  87 

of  vagina,  43 

Comparison  between  ligature  and  forceps 
in  vaginal  hysterectomy,  488 

between  total  extirpation  and  supra- 
vaginal  amputation  of  uterus, 
498 

between  vaginal  and  abdominal  section, 
for     carcinoma     of     uterus, 

520 

for  fibroid  of  uterus,  493 
for       salpingo-oophorectomy, 

540 

Conception,  incapacity  for,  683 
Condurango,  515 
Condylomata  acuminata,  277 
Cone-mantle-shaped   excision  of  cervix, 

419 

Conium  pills,  243 
Connective  tissue,  pelvic,  93 
Consent  of  patient  necessary  for  opera- 
tions, 534 


INDEX. 


697 


Conservative  treatment  of   appendages, 

533,  562 
Copeland,  method  of  arresting  vomiting, 

192 

Copiopia,  247 
Copulation,  121 

incapacity  for,  683 
Corpora  arenacea,  581 
Corpus — 

albicans,  74 

cavernosum  of  clitoris,  38 

luteurn — 
calcined,  561 
changed  into  cyst,  561 

into  gyroma,  564 
false,  73 

of  menstruation,  70 
of  pregnancy,  71,  565 
ossified,  561 
verum,  565 

nigricans,  74 

uigrum,  74 

uteri,  47 
Corpuscles — 

Bennett's  large,  576 
small,  578 

colloid,  578 

Drysdale's,  579 

gorged,  577 

Nunn's,  577 
Corroding  ulcer  of  cervix,  424 

different  from  rodent  ulcer,  512 
Corset,  129 

Cortical  substance  of  ovary,  67 
Cotton,  styptic,  182 
Counter-irritation,  188 
Counter-pressure  hook,  219 
Courses,  115 
Court}',  inversion,  465 
Cramps,  404 
Creolin,  173,  205 
Crosby,  needle-holder,  215 
Crus  of  clitoris,  38 
Curette,  153 

Kecamier's,  177 

Simon's,  153 

Sims's,  153 

Thomas's  dull-wire,  153 
Curetting,  176 

for  uterine  fibroids,  481 
Current — 

constant,  232 

interrupted,  232 
Cusco,  speculum,  144 
Cyst— 

of  abdominal  wall,  601 

of  broad  ligament,  597,  600,  645 

of  cervix,  413,  467 

of  Fallopian  tube,  546 


Cyst— 

of  liver,  600 

of  mesentery,  (501 

of  omentum,  600 

of  ovary,  567 

of  pancreas,  601 

of  spleen,  601 

of  uterus,  467 

of  vagina,  358 

of  vulva,  283 

of  vulvovaginal  gland,  289 

ovarian,  567 

parovarian,  645 

renal,  600 

tubo-ovarian,  583 
Cystocarcinoma  of  ovary,  639,  641 
Cystocele,  335 
Cystoma  of  ovary — 

dermoid,  581 

glandular,  572 

myxoid,  571 

papillary,  572,  580 
Cystopexy,  339 
Cystosarcoma  of  uterus,  504 
Cystoscope,  152,  162 
Czerny,  ventrofixation,  452 
Czerny-Lembert  suture,  617 

D. 

Davidson,  syringe,  171 
Death — 

after  hysterectomy,  501 

after  ovariotomy,  635 

from  chloroform,  208 
Decidual  sarcoma,  506 
Depressor — 

Garrigues',  149 

Hunter's,  147 

Sims's,  147 

vaginal,  147 
Dermoid  cyst — 

of  ovary,  581 

outside  of  ovary,  583 
Descent — 

of  ovary,  23 

of  uterus,  454 
Detrusor  of  rectum,  87 
Development — 

arrest  of,  of  uterus,  387 

excessive,  of  uterus,  387 

irregular,  of  uterus,  394 

of  the  female  genitals,  19 
Diaphragm,  pelvic,  97 
Diet- 
after  operations,  224 

fluid,  224 

for  reducing  fat,  686 
Dieulafoy,  aspirator,  159 


698 


INDEX. 


Digital  pressure  for  replacing  uterus,  446 
Digitalis  for  reviving,  210 
Dilatation — 

of  cervical  canal,  154,  184 

of  urethra,  142,  163 

of  uterus,  156 
Dilator- 
blunt  pelvic,  624 

Garrigues',  155 

Hanks's,  155,  156 

Outerbridge's,  184 

sharp-pointed  pelvic,  624 
Discus  proligerus,  28,  69 
Disease,  gelatinous,  of  peritoneum,  587 
Diseases — 

exanthematous,  271 

of  broad  ligament,  644 

of  Fallopian  tube,  524 

of  ovary,  549 

of  pelvis,  643 

of  perineum,  301 

of  round  ligament,  648 

of  sacro-uterine  ligament,  648 

of  uterus,  387 

of  vagina,  326 

of  vulva,  255 

of  vulvovaginal  gland,  289 

venereal,  291 
Disinfection,  198 

by  steam,  199 

internal,  385 

of  instruments,  215 

of  laminaria  tents,  154 

with  boiling  soda  solution,  199 
Displacement — 

of  Fallopian  tube,  546 

of  ovary,  550 

of  uterus,  433 
Distribution  of  organs  between  perineal 

fasciae,  109 
Douche-can,  171 
Douglas's  pouch,  91 

prolapse  of  intestine  into,  335 
Dowd,  sterilizer  for  catgut,  203 
Drainage — 

abdominal,  181,  185,  629 

after  ovariotomy,  629 

of  uterus,  180, 184 

-tube,  185 

vaginal,  630,  665 
Dress,  128 
Drink,  224 

Dropsy  of  Graafian  follicle,  568 
Dudley,  E.  C.,  operation  for  anteflexion, 

442 
Dysmenorrhea,  242 

membranous,  242,  415 

nervous,  242 

obstructive,  421 


Dyspareunia,  121 
Dyspepsia,  225 


E. 


Echinococci,  679 
Ecphyadectomy,  691 
Ectropium,  396,  407 
Edebohls,  table,  195 
Edema — 

indurating,  285 

of  abdominal  wall,  601 

of  lacerated  perineum,  305 
Education,  127 
Ehrich,  speculum,  148 
Elastic  ligature,  how  to  tie,  497 

pressure,  464 
Electricity — 

Apostoli's  method,  233 

bipolar  electrode,  229 

chemical,  230 

galvanocauterization  of  the  cervix,. 
234 

different  qualities  of  poles,  233 

frictional,  229 

high-tension  coil,  230 

inductional,  229 

molecular  movement,  233 
Electrode— 

aluminium,  231 

Apostoli's,  230,  231 

bipolar,  229 

Engelmann's,  231 

Fry's,  423 

Garrigues',  231 

gas-carbon,  232,  233 

Goelet's,  231 

Martin's,  231 

platinum,  231 
Electrolysis,  232 

for  stenosis  of  cervix,  423 

metallic  interstitial,  236 
Elephantiasis  of  vulva,  279 
Elevation  of  uterus,  460 
Elytritis,  343 
Emmenogogues,  240 
Emmet,  Bache,  trocar-forceps,  666 
Emmet,  T.  A.,  aspirator,  159 

button-hole  operation,  297 

counter-pressure  hook,  219 

operation  for  fecal  fistula,  384 
for  inversion,  465 
for  lacerated  cervix,  399 
for  uterine  fibroid,  482 
for  vaginismus,  357 
for  vesico-uterine  fistula,  37fr 

perineorrhaphy,  316,  320 

pessary,  446 

tenaculum,  212 


INDEX. 


699 


Emmet,  T.  A.,  trocar,  611 

wire-twister,  219 
Emphysema,  634 
Ems,  188 

Emulsion  of  camphor,  351 
Enchondroma — 

of  clitoris,  281 

of  uterus,  522 

Encysted  peri  ton  itic  exudation,  599 
Endocervicitis,  404 
Endometritis,  403 

atrophic,  409 

catarrhal,  407 

chronic,  407 

decidual,  409 

exfoliating,  415 

fungous,  408 

hemorrhagic,  409,  420 

hyperplastic,  408 

menstrual,  415 
Endosalpiugitis,  525 
Endothelioma  (Ackermann)  of  ovary,  639 

(Jones)  of  ovary,  563,  565 
Enemas,  174 
Eogelmann,  electrode,  231 

retractor,  211 
Enterocele,  vaginal,  334 
Enucleation — 

abdominal,  498 

from  broad  ligament,  499 

from  pelvic  floor,  499 

from  uterus,  500 

Miner's  method,  621 

of  uterine  fibroids,  481,  498,  499 

vaginal,  481 

Enuresis,  operations  for,  339,  379 
Epididymis,  22 
Episiocleisis,  378 
Epispadias,  256 

Epithelial  coalescence  of  vulva,  258 
Epithelioma  of  vulva,  283 
Erection,  121 

of  internal  genitals,  57 
Ergot,  hypodermically  for  fibroids,  480 
Ergotine,  480 

Erosions,  408,  413,  424,  513 
Erysipelas  of  vagina,  353 
Esmarch,  mask,  208 
Esthiomene,  285 
Ether,  206 

chloric,  210 
Ethyl  chloride,  210 
Examination — 

bimanual,  141 

chemical,  161 

combined,  141,  142 

digital,  139 

for  sterility,  686 

in  general,  132 


Examination — 

in  regard  to  operations,  196 

intestinal,  142 

microscopical,  161 

of  abdomen,  157 

of  bladder,  161 

of  pelvis,  139,  531 

of  ureters,  159 

of  urine,  160 

of  uterine  appendages,  531 

of  virgins,  156 

physical,  135 

rec'tal,  142 

under  anesthesia,  161 

vaginal,  140 

verbal,  132 

vesical,  142 

Exanthematous  diseases,  271 
Excitor — 

bipolar,  229 

uterine,  229 

vaginal,  229 
Excretions,  128 
Exercise,  127 
Exploratory — 

aspiration,  159,  595 

incision,  159,  596 

laparotomy,  533 

puncture,  595 
Extraperitoneal  shortening  of  the  round 

ligament,  448 
Extra-uterine  pregnancy,  597 

F. 

Facies  ovariana,  591 
Falling  of  the  womb,  454 
Fallopian  tubes — 

absence  of,  524 

accessory,  524 

anatomy,  62 

cancer,  547 

carcinoma,  547 

catheterization  of,  533 

cysts,  546 

development,  30 

diseases  of,  524 

displacement,  546 

examination  of,  531 

fibroma,  547 

function,  64 

lipoma,  547 

malformation,  524 

neoplasms,  546 

palpation,  531 

papilloma,  547 

relation  to  menstruation,  118,  120 

sarcoma,  547 

tuberculosis,  547 


700 


INDEX. 


Faradism,  229 

Faradization  of  diaphragm,  210 
Fascia — 
anal,  95,  101 
deep  perineal,  100 
distribution  of  organs  between  perineal 

fasciae,  109 
levator,  101 
obturator,  94 
pelvic,  94 
perineal,  100 
pyriformis,  94 
superficial  perineal,  100 
vesicorectal,  94 
Fat— 

-granules  in  ovarian  cysts,  579 
preperitoneal,  610 
retropubic,  93 

Fecal  fistula  after  ovariotomy,  634 
Feces,  impacted,  602 
Fecundation,  121 
Fergusson,  speculum,  144 
Fertilization,  121 
Fibrocyst  of  ovary,  536 
of  uterus,  573 
diagnosis,  598 
treatment,  503 
Fibroid — 

of  uterus,  469,  597 
calcification,  474 

causes  of  death  from  operations,  501 
complication  with  pregnancy,  500 
diagnosis  from  ovarian  cyst,  598 
indications  for  operations,  503 
mortality  after  operations,  500 
sloughing,  500 

of  vagina,  359.    (See  Fibroma,  Myoma..) 
Fibroma — 

molliiscum,  281 
of  Fallopian  tube,  547 
of  ovary,  636 
of  round  ligament,  264 
of  uterus,  469 
of  vagina,  359 
of  vulva,  280 

case  of  pedunculated,  281.     (See  Fi- 
broid, Myoma.) 
Fibromyoma — 
of  uterus,  469 

of  vagina,  359.    (See  Fibroid,  Fibi-oma.) 
Plbrosarcoma  of  ovary,  638 
Fimbria  ovarica,  63 
Fimbrise — 
anatomy,  63 
development,  30 
Fistula,  363 

abdominal  method,  371 
Bandl's  method,  373 
Barton's  method,  382 


Fistula — 

Blasius's  method,  369 

Bozeman's  method,  368 

Bureau's  method,  384 

combination  of  methods,  372 

congenital  rectovaginal,  334 

denudation,  366 

Emmet's  method,  376 

entero-vaginal,  380,  385 

fecal,  380,  634 

flap-splitting  methods,  369,  384 

Follet's  method,  376 

Fritsch's  method,  384 

ileo-uterine,  380 

ileovaginal,  380 

Pozzi's  method,  375 

produced  by  coition,  265 

rectolabial,  380 

rectovaginal,  380,  382 

rectovtilvar,  265,  380 

Schede's  method,  374 

Simon's  method,  368 

Sims's  method,  366 

suprapubic  method,  369 

Taylor's  method,  383 

Trendelenburg's  method,  369 

uretero-uterine,  377 

ureterovaginal,  371,  373 

ureterovesicovaginal,  377 

urethrovaginal,  372 

urinary,  363 

uterovaginal,  397 

vesico-uterine,  376 

vesico-uterovaginal,  377 

vesico vaginal,  363 

Vignard's  method,  384 

Walcher's  method,  370 
Fistulous  tract,  634,  668 
Flap-operation  for  atresia,  331 
Flap-sliding     method    for     rectovaginal 

fistula,  384 

Flap-splitting  perineorrhaphy,  307 
Flatus  vaginalis,  323 
Fluid— 

in  cysts  of  broad  ligament,  646 

in  ovarian  cysts,  570,  576,  583,  595 

in  uterine  fibrocysts,  473 
Fluids,  antiseptic,  205 
Foerster,  table,  195 
Fostus  in  foetu,  588 
Follet,  vesico-uterine  fistula,  376 
Folsom-Skene,  speculum,  151 
Fomentation,  187 
Food,  128,  224 
Forceps — 

artery-,  184 

compared  with  ligature,  488 

cyst-,  611 

dressing-,  150 


INDEX. 


701 


Forceps — 

hemostatic,  184,  485 

intra-uterine,  packing-,  180,  181 

pedical-,  612 

pressure-,  184,  214,485 

tenaculuin-,  213 

tissue-,  213 

tongue-,  209 

traction-,  212 

trocar-,  666 
Forcipressure,  184 

used  in  hysterectomy,  485 
Foreign  bodies — 

in  uterus,  403 

in  vagina,  342 
Fornix  of  vagina,  42 
Fossa — 

ischiorectal,  101 

navicularis,  40 
Fourchette,  36 
Fowler,  pessary,  447 
Franklinism,  229 
Franzensbad,  188 
Frenulum  of  clitoris,  37 
Freund,  hysterectomy,  520 

operation  for  prolapse  of  uterus,  458 
Fritsch,  enucleation,  499 

hysterectomy  for  prolapse,  458 

operation  for  fecal  fistula,  384 
Frost,  vaginal  syringe,  673 
Fry,  electrode,  423 
Fund  us — 

of  bladder,  78 

of  uterus,  47 
Fusion  of  ovarian  cysts,  585 

G. 

Gall-bladder  torn  in  ovariotomy,  618 
Galvanism,  230 
Galvanocauterization — 

chemical,  233,  234,  480 

for  carcinoma  of  uterus,  516,  517 

for  extirpation  of  uterus,  518 

thermal,  235 
Galvanochemical  cauterization  for  uterine 

fibroids,  480 
Galvanopuncture,  235 
Ganglion,  cervical,  61 
Gangrene — 

of  uterus,  432 

of  vagina,  352 

of  vulva,  270 
Gariel,  air-pessary,  456 
Garrigues,  apparatus  for  transfusion  and 
infusion,  502 

colpoperineorrhaphy,  311 

dilator,  155 

intra-uterine  electrode,  231 


Garrigues,  intra-uterine  pack  ing- forceps, 

curved,  180;  straight,  181 
tube,  173 

perineal  pad,  304 

serrefines,  303 

weight  speculum,  211 
Garrulity  of  vulva,  323 
Gartners  canal,  20,  358 
Gas  artificially  developed  in  stomach,  158 
Gauze — 

balls,  201 

pads,  201 

sponges,  201 
Gehrung,  pessary,  435 
Gelatinous  disease  of  peritoneum,  587 
Genital — 

cleisis,  378 

cord,  31 

corpuscles,  39 

folds,  33 

furrow,  34 

tubercle,  33 
Genitals — 

external,  35 

internal,  35 
Geode,  463 
Germ-epithelium,  28 
Germinal — 

spot,  70 

vesicle,  70 

Gestation,  incapacity  for,  684 
Glands — 

Bartholin's,  40 

C'hampionniere's,  61,  677 

coccygeal,  103 

Littre's,  76 

mammary,  114 

of  isthmus,  61,  677 

pelvic,  62,  508 

Skene's,  76 

utricular,  50 

vulvovaginal,  40,  289 
Glandulae  vestibulares  majores,  41 

minores,  39 

Glass  plug  for  vagina,  330 
Glycerine  tampon,  178 
Glycerite  of  tannin,  178 
Goelet,  electrode,  231 

intra-uterine  tube,  173 
Gold,  226 

Goltz's  experiment,  631 
Gonococcus,  344,  347 
Gonorrhea,  131,  267,  269,  291,346,406, 
529,  558,  659 

danger  of,  131 

latent,  131,  682 
Gordon,  S.  C.,  excision  of  cervix.  418 

operation  for  chronic  metritis,  418 
Gossypii  radicis  cortex,  227 


702 


INDEX. 


Graafian  follicl 

anatomy,  67,  68 

development,  26 

dropsy,  568 

Gram's  method  of  finding  gonococcus,  344 
Granular  os,  408,  424 
Greenhalgh,  metrotome,  422 
Gymnastics,  191 
Gynecological  treatment,  cause  of  disease, 

131 
Gyroma,  563 

H. 

Hagedorn,  needles,  214 

needle-holder,  215 
Hallucinations  due  to  lacerated  cervix, 

397 

Hanks,  dilators,  155, 156 
Heart- 
artificial  contraction,  207 

examination  in  regard  to  operation,  196 
Heat,  187 
Heels,  high,  128 

Hegar,  amputation  of  cervical   portion, 
418 

colpoperineorrhaphy,  311,  314 

extra-abdominal  treatment  of  pedicle 
in  hysterectomy,  497 

funnel-shaped  excision  of  cervix,  427 

operation  for  chronic  metritis,  418 
for  fecal  fistula,  385 
for  pelvic  abscess,  657 

sacral  hysterectomy,  520 
Helicine  arteries,  59 
Hematocele,  597,  649,  650 

of  the  canal  of  Nuck,  263 
Hematocolpos,  326 
Hematoma — 

of  broad  ligament,  597,  655 

of  ovary,  554 

of  round  ligament,  263 

of  vagina,  342 

of  vulva,  276 

pudendal,  265 
Hematometra,  326,  389,  421 
Hematosalpinx,  326,  525,  545 
Hemorrhage — 

at  climacteric,  126 

from  torn  hymen,  341 

from  wound  in  vulva,  41 

in  hysterectomy,  501 

in  ovarian  cysts,  585,  593 

in  perineal  region,  108 

internal,  after  ovariotomy,  631 

intraperitoneal,  631 

pelvic,  649 
Hemostasis,  181 

after  ovariotomy,  627 


Hemostatic — 

drugs,  227 

vaginal  plug,  179 
j  Heredity,  127 
Hermaphrodism,  258 
,  Hermaphroditism,  258 
Hernia — 

anterior  labial,  260 

crural,  of  ovary,  550 

in  the  canal  of  Nuck,  261 

inguinal,  of  ovary,  550 

inguinolabial,  260 

posterior  labial,  261 

umbilical,  complicating   ovarian   cyst, 
629 

uteri,  394,  466 

vaginal,  334 

vaginolabial,  261 
Herpes  progenitalis,  271 
Hewitt,  cradle  pessary,  435 
High-tension  current,  230 
Hilum,  66 
Hodge,  pessary,  446 
Hofmeier,  enucleation,  499 
Horn  of  clitoris,  382 
Horns  of  uterus,  31 
Horn-cells,  578 
Horsehair,  204 
Hot  water,  182 
Hot- water  bag,  187 
Hottentot  apron,  37 
Houston's  valves,  87 
Hunter,  J.  B.,  needle,  488 
Hydatid— 

of  liver,  600 

of  Morgagni,  30,  524 

of  pelvis,  679 
Hydramuion,    diagnosis    from     ovarian 

cyst,  598 

Hydrobromate  of  hyoscine,  226 
Hydrocele,  262 
of  ovary,  583 

intermittent,  525,  584 
Hydroleine,  252 
Hydrometra,  125,  392,  421,  598 
Hydronaphthol,  206 
Hydronephrosis,  600 
Hydrops — 

folliculi,  567 

tubae  profluens,  525,  584 
Hydrorrhea,  410 

gravidarum,  410 

puerperal,  410 

Hydrosalpinx,  525,  544,  597,  601 
Hydrotherapy,  188 
Hygroma,  325 
Hymen — 

abnormal  openings  in,  328 

absent,  326 


INDEX. 


703 


Hymen — 

anatomy,  46 

atresia,  326 

bifenestratus,  328 

biforis,  328 

cribriformis,  328 

development,  33 

double,  328 

fleshy,  328 

hemorrhage  from  torn,  341 

malformations,  326 

septus,  328 

subseptus,  328 
Hyperemia — 

of  ovaries,  554 

of  pelvis,  127 

Hyperesthesia  of  vulva,  275 
Hyperplasia  of  vulva,  275,  285 
Hypertrophy  of  uterus,  425 

infravaginal,  425  « 

supravaginal,  426 
Hypnotics,  226 
Hypospadias.  255 
Hysteralgia,  432 
Hysterectomy,  483 

abdominal,  431,  493,  520 

compared  with  vaginal  method,  493 

Bardenheuer's  method,  491 

causes  of  death,  501 

extra-abdominal  treatment  of  pedicle, 
497 

for  carcinoma  uteri,  517 

for  hemorrhagic  endometritis,  420 

for  prolapse,  458 

for  supravaginal  hypertrophy  of  cer- 
vix, 431 

for  uterine  fibroid,  483 

intra-abdominal  treatment  of  pedicle, 
496 

Jacobs's  method,  492 

Martin's  method,  493 

mortality,  500 

perineal,  520 

perineovaginal,  520 

Pratt's  method,  491 

retroperitoneal  treatment  of  pedicle,  496 

sacral,  519 
.  special  difficulties,  494 

supravaginal     amputation     compared 
with  total  extirpation,  498 

vaginal,  431,  458,  483,  490,  674 
compared  with  abdominal,  493 

vagino-abdominal,  491 

with  galvanocautery,  518 

with  ligatures,  487,  517 

with  pressure-forceps,  483 

with  thermocautery,  518 

without  ligature  or  forceps,  490 
Hysteria,  247 


Hysterocele,  466 
Hysterocleisis,  378 
Hysterocystocleisis,  378 
Hystero-epilepsy,  247 
Hysteropexy,  450 

abdominal,  452 

vaginal,  450 
Hysterotrachelorrhaphy,  399 

I. 

Ice-bag,  187 
Ichthyol  glycerine,  178 
Impotence,  682 
Impregnation,  artificial,  687 
Incision  — 

exploratory,  159,  596 

of  vaginal  vault,  533 
Incontinence  of  urine,  operation  for,  339, 

379 

Incubation,  294 

Indurating  edema  of  syphilis,  285 
Induration,  absent,  294 
Inflammation,  perimetric,  657 
Infusion  of  salt  solution,  502 
Inhaler — 

Allis's,  207 

Esmarch's,  208 

Ormsby's,  208 
Injections,  171 

antiseptic,  172 

astringent,  172 

cleansing,  172 

emollient,  172 

hot-water,  182 

hypodermic,  before  operations,  197,  208, 
209 

intestinal,  for  diagnosis,  158 

intraperitoneal,  176 

intra-uterine,  172 

intravenous,  176,  207 

rectal,  174 

subcutaneous  saline,  176,  502 

vaginal,  171 

vesical,  175 
Injuries — 

of  body  of  uterus,  394 

of  cervix,  396 

of  intestine,  617 

of  perineum,  301 

of  uterus,  394 

of  vagina,  341 

of  vulva,  265 
Insanity,  247 
Inspection — 

of  abdomen,  157 

of  genitals,  139 
Instruments — 

common,  211 


704 


INDEX. 


Instruments — 

disinfection  of,  199 

how  to  clean,  223 

needed  in  all  operations,  211 
in  ovariotomy,  607 

selection  of,  223 
Intermenstrual  pain,  404 
Intermittent  hydrocele  of  ovary,  503 
Interpolar  effect,  232 
Intestinal — 

obstruction,  502,  594,  632 

surgery,  688 
Intestine — 

adherent  to  tumors,  495,  617 

anastomosis,  688 

button  operation,  690 

injury  during  ovariotomy,  617 

invagination,  689 

laid    on    abdominal    wall,    535,    620, 
628 

resection,  688 

Schroeder's     method     of     repairing, 
495 

surgery,  688 

Invagination  theory,  588 
Inversion — 

instrumental  replacement,  465 

manual  replacement,  465 

of  uterus,  460 

of  vagina,  340 

operations  for,  465 

partial,  460 

total,  460 
lodoform,  205 

bougies,  407 

ointment,  178 

solution  with  tannin,  412 

suppositories,  226,  324,  407 
lodol,  218 

Iron   contraindicated  in  uterine  hemor- 
rhage, 228 

pills,  225 
Irrigation  with   hot   antiseptic  solution, 

182,  222 

Irrigator  for  bladder,  175 
Irritable — 

bladder,  409,  413 

vascular   excrescence   of  the   urethra, 

282 

Ischuria  paradoxa,  602 
Isthmus — 

of  Fallopian  tube,  63 

of  uterus,  49 

J. 

Jacobs,  hysterectomy,  492 
Jackson,  speculum,  150 
Jay,  urinal,  379 


K. 

Kaltenbach,  supravaginal  amputation  of 

cervix,  429 
Kangaroo  tendon,  204 
Keith,  opinion  about  Apostoli's  method, 

481 
Kelly,  catheterization  of  ureter,  163 

rubber  cushions,  194 

suspensio  uteri.  452 

trocar,  611 

ventrofixation,  452 
Kelsey,  speculum,  150 
Keyes,  irrigator,  175 
Kidney — 

extirpation,  619 

floating,  600 
Kleptomania,  247 
Knives,  213 

uterine,  422 
Knot,  surgical,  217 

Staffordshire,  536 
Koeberle",  artery  clamp,  182 
Koenig,  method  of  reviving,  207 
Kraske,  hysterectomy,  519 
Kraurosis  vulvse,  288 
Kreuznach,  188 
Kiichenmeister,  scissors,  422 
Kiistner,  flap-operation  for  atresia,  331 

L. 

Labarraque,  solution,  668 
Labia  majora — 
abnormal,  258 
anatomy,  36 
function,  37 
Labia  minora — 
anatomy,  37 
function,  37 

Labor,  ovarian  cyst  during,  629 
Laceration — 
of  cervix,  396 
of  perineum,  301 
complete,  302,  305,  310,  314,  320 
incomplete,  302,  303,  307,  311,  316 
intermediate  operation,  307 
primary  operation,  303 
secondary  operation,  307 
of  vaginal  entrance,  305 
Lack  of  orgasm,  687 
Latninaria,  disinfection  of,  154 
Lamp,  electric,  628 
Laparotomy,  609 
compared   with    vaginal    section,   493, 

520,  540 
for  sterility,  687 
Late  hours,  129 
Lateroflexion,  394.  454 
Lateroposition,  394 


INDEX. 


705 


Lateroversion,  394,  454 

Lauenstein,  suture,  316 

Leavens,  sutures,  200 

Leech,  artificial,  186 

Leeches,  186 

Lefort's  operation  for  prolapse  of  uterus, 

457 

Leg-holder,  198 
Leggings,  197 
Leopold,  ventrofixation,  452 

apparatus  for  Trendelenburg's  position, 

139,  195 

Leptothrix  vaginal  is,  349 
Leucorrhea,  250 

in  phthisis,  252 
Ligaments — 
broad,  56,  644 
infundibulopelvic,  25,  64 
intern  reteric,  81 
of  bladder,  80 

anterior  true,  80,  95 
false,  80 
lateral  false,  80 

true,  80,  95 
posterior  false,  80 
superior  false,  80 
suspensory,  80 
true,  80 

vesico-uterine,  55,  80 
of  ovary,  anatomy,  65 

development,  23 
of  rectum,  96 
of  uterus,  54 
perineal,  100 
pubovesical,  76,  95 
round, 58 
sacro-uterine,  55 
subpubic,  100 
superior  round,  57 
suspensory,  of  clitoris,  38 
transverse,  of  pelvis,  100 
triangular,  of  urethra,  100 
vesico-uterine,  55,  80 
Ligamentum  suspensorium    of   bladder, 

80 
Ligation  of  pedicle  of  ovarian  cyst,  612, 

625.     (See  Ligature.) 
Ligature — 
-box,  202 
-carrier,  217 
chain-,  625 

compared  with  forceps,  488 
elastic,  217,  465,  496 
for  fecal  fistula,  383 
in  ovariotomy,  628 
mass-,  182 
material,  217 

method  for  hysterectomy,  487 
of  arteries,  182 

45 


Ligature — 

of  internal  iliac  artery,  521 

of  internal  pudic  artery,  183 

of  uterine  artery,  182 
Li  pom  a — 

of  Fallopian  tube,  547 

of  vulva,  281 

Lips  of  cervical  portion,  48 
Liquor — 

ferri  chloridi,  179 

folliculi,  28,  70 
Liver —    - 

adhesions,  618 

floating,  600 
Lotion  to  be  used  with  tincture  of  iodine, 

188 
Lotions — 

carbolic  acid,  188,  272,  293 

chloral  hydrate,  269 

hydrocyanic  acid  and  lead,  269 
Lubricant,  140 

Lungs,  examination  in  regard  to  opera- 
tions, 196 

Lupus  of  vulva,  285 
Lymphadenitis,  pelvic,  676 
Lymphangitis,  pelvic,  676 
Lymphatics — 

of  perineal  region,  108 

of  uterus,  62 
Lysol,  206 

M. 

Malformations — 

of  Fallopian  tubes,  524 

of  hymen,  326 

of  ovaries,  549 

of  pelvic  peritoneum,  643 

of  uterus,  387 

of  vagina,  326,  328 

of  vulva,  255 

Malignant      tumor      diagnosticated     by 
cancer  cells  in  ascitic  fluid,  513 
Malposition  of  uterus,  394 
Afammary  gland,    normal    development 

simulating  tumor,  114 
Manual  replacement  of  inverted  uterus, 

465 
Marcy,  cobbler's  stitch,  626 

needle,  215 

subcuticular  suture,  493 
Marienbad,  188 
Marriage — 

as  a  cure,  244 

in  relation  to  disease,  129 
Marsiipialization,  623,  647 
Martin,  A.,  enucleation,  499 

hysterectomy,  493 
Martin,  E.,  pistol,  171 


706 


INDEX. 


Massage,  190 

for  adhesions,  450 
Masturbation,  297 

Maunsell,  artificial   invagination   of  in- 
testine, 689 
Mayer,  pessary,  456 
Mayhem,  534 
McNaughton,  apparatus  for  Trendelen- 

burg's  position,  195 
Meatus  urinarius,  39 
Medullary  substance  of  ovary,  67 
Metnbrana  granulosa,  28,  69 
Menopause,  123 

treatment,  125 
Menorrhagia,  245 
Menses,  115 

suppression  of,  238 
Menstrual — 

disorders,  247 

period,  115 
Menstruation,  115 

abnormal,  238 

coition  during,  130 

influence  of  operation,  119,  539 

neglect  during,  129 

operations  during,  192 

precocious,  244 

scanty,  241 

supplementary,  241 

tardy,  245 

theory  of,  120 

vicarious,  241 
Mensuration,  158 

Mental  aberration  after  ovariotomy,  635 
Mercury,  bichloride,  205,  516 
Mesentery,  adhesions,  618 
Mesoarium,  23 
Mesorchium,  23 
Mesorectum,  86 
Mesosalpinx,  25,  64 
Metastasis — 

from  ovarian  cysts,  586 

from  uterine  carcinoma,  509,  511 
Methyl  blue,  515 
Metritis,  403 

acute,  403 

chronic,  407 

parenchymatous,  416 

diphtheritic,  406 

dissecting,  406 

gonorrheal,  406 

operations  for,  418 

parenchymatous,  403 
Metrorrhagia,  247 
Metrotome — 

Greenhalgh's,  422 

Simpson's,  422 

Mikulicz,  abdominal  tamponade,  181,  499 
Milliampereraeter,  232 


Miner,  enucleation,  621 

Mirror,  concave,  for  throwing  light  into 

abdominal  cavity,  628 
Mitchell,  Hubbard,  speculum,  147 
Mitchell,  S.  Weir,  rest-cure,  225 
Mixtures — 

A.  C.  E.,  206 

condurango,  515 

hydrocyanic  acid,  211 

pepsin,  225 

potash  and  belladonna,  269,  413 

strychnine,  226 

Molecules  moved  by  electric  current,  233 
Molimina,  133,  139" 
Mons  Veneris — 

anatomy,  35 

function,  35 
Monsel's  solution — 

in  enucleation  of  fibroid,  499 
in  ovariotomy,  628 
Monthly — 

flow,  115 

sickness,  115 
Morcellation,  479,  489 
Morgagni,  hydatid  of,  30,  524 

lacunae  of,  76 
Morphine  injected  subcutaneously  before 

anesthetizing,  208 
Miillerian  duct,  29 
Munde",  speculum,  147 
Murphy,  button,  690 
Muscles — 

bulbocavernosus,  102 

coccygeus,  97 

compressor  urethra3,  103 

constrictor  urethra3,  103 
vaginae,  104 

deep  trans  versus  perinsei,  104 

depressor  urethne,  103 

detrusor  recti,  87 

external  sphincter  ani,  87 

Giithrie's,  103 

internal  sphincter  ani,  87 

ischiocavernosus,  102 

ischiococcygeus,  97 

Jarjavay's,  103 

levator  ani,  97 

obturatococcygeus,  97 

perineal,  102 

pubococcygeus,  97 

superficial  transversus  perinaei,  103 

third  sphinter  of  rectum,  87 

transversus  urethrse,  103 
Myofibroma — 

of  uterus,  469 

of  vagina,  359.    (See  Fibroid,  Fibroma, 

Fibromyoma,  Myoma.) 
Myoma — 

cavernous,  of  uterus,  469 


INDEX. 


707 


Myoma — 

complicating  ovarian  cyst,  629 

lymphangiectodes,  469 

of  uterus,  469 

of  vagina,  359 

of  vulva,  281 

teleangiectodes,  469.     (See  Fibroid.  Fi- 
broma.) 

Myxoid  cystoma,  571 
Myxoma — 

of  uterus,  467 

of  vulva,  281 
Myxosarcoma — 

of  ovary,  638 

of  uterus,  504 

ir. 

Naboth,  ovula  of,  407,  410 
Neck  of  womb,  47 
Needles,  214 

handled,  216 

Hunter's,  488 

Marcy's,  215 

perineum,  417 

Folk's,  487 

Rchroeder's,  487 
Needle-holder — 

Crosby's,  215 

Hagedorn's,  215 

Sims' s,  215 
Neglect  of  skin,  127 
Negro,  carcinoma,  509 

uterine  fibroid,  474 
Ne"laton  artificial  respiration,  207 

cyst-forceps,  611 
Neoplasms — 

of  Fallopian  tube,  547 

of  ovary,  567 

of  uterus,  467 

of  vagina,  358 

of  vulva,  277 

Nerves  of  perineal  region,  108 
Neuralgia — 

lumbo-abdominal,  411 

of  uterus,  432 
Neuroma  of  vulva,  282 
Nitroglycerin,  210 
Noeggerath,  inversion,  465 

latent  gonorrhea,  131 
Nott,  catheter,  175 
Nozzle  with  stopcock,  198 
Nubility,  114 

Nuck,  canal  of,  37,  59,  263,  643 
Nunn's  gorged  corpuscles,  577 
Nussbaum,  suprapubic  urethra,  378 
Nymphae — 

anatomy,  37 

progressive  atrophy,  288 


O. 

Obliquity  of  uterus,  384 
Occlusion  dressing,  304 
Oi'dium  albicans,  349 
Ointments — 

chloral  hydrate,  269 

condurango,  515 

iodoform,  178 
Ointment-carrier,  171 
Olshausen,  ventrofixation,  452 
Omentum  adherent  to  tumors,  495,  618 
Oophoralgia,  642 
Oophorectomy — 

for  atresia,  332 

for  uterine  fibroids,  483.     (See  Salpingo- 

oophorectomy.) 
Oophoritis,  557 

acute,  557 

chronic,  559 

follicular,  557 

interfollicular,  557 

transition  to  cyst,  560 
Oozing  tumor,  278 
Operating-room,  193 
Operating-table,  194 

Boldt's,  195 

Bozeman's,  368 

Cleveland's,  195 

Foerster's,  195 
Operations — 

after-treatment,  323 

Alexander's,  448 

assistants,  195 

combined,  223 

diet  after,  224 

disinfection,  199 

during  hot  season,  192 

during  lactation,  193 

during  menstruation,  192 

during  pregnancy,  192 

for  incontinence,  379 

in  general,  192 

instruments  which  are  used  in  nearly 
all,  211 

preparation  for,  193 
of  patient,  196 

room,  193 

rubber  cushions,  194 

spectators,  196 

table  for,  194 

time  of  day  for,  183 

vessels  needed  in,  198 
Opium — 

pills,  243 

suppositories,  226 
Organ  of  Giraldez,  22 
Orgasm,  121 

lack  of,  687 


708 


INDEX. 


Ormsby,  inhaler,  208 
Os— 

externum,  48 
granular,  408,  424 
internum,  40 
pinhole,  421 
tincne,  48 
uteri,  48 

Osmosis,  electrical,  233 
Ossification — 

of  corpus  luteum,  561 
of  ovarian  cysts,  586 
Ostium — 

abdoininale  of  Fallopian  tube,  63 
accessory     abdominal,     of     Fallopian 

tube,  524 

uterinum  of  Fallopian  tube,  63 
Outerbridge,  instrument  for  uterine  dila- 
tation and  drainage,  184 
perineorrhaphy,  318 
Ova- 
absence  of,  683 
anatomy,  70 
development,  26 
expulsion,  74,  117 
formation,  26 
primordial,  28 
Ovarian — 
abscess,  557 
cyst — 

adherent  everywhere,  619 

adhesions,  585,  616,  619 

ascites,  594 

blood  corpuscles  in  fluid  of,  576 

calcification,  586 

cancerous  degeneration,  576,  586,  639 

cholesterin  in,  579 

complicated  with  labor,  629 

complications,  602,  629 

congenital,  574 

contents,  576,  583 

cut  off  blood-supply  from,  624 

dermoid,  581 

diagnostic  value  of  examination  of 

fluid,  595 

differential  diagnosis,  596 
epithelial  cells  in  fluid  of,  577 
etiology,  588 
explorative — 
incision,  596 
puncture,  595 
extraperitoneal,  585 
diagnosis,  602 
fluid,  570.  576,  583,  595 
fusion,  585 
glandular,  572 
hemorrhage,  585,  593 
in  mesentery,  622 
inflammation,  593 


Ovarian  cyst — 

intestinal  obstruction  caused  by,  594 

intraligamentous,  585,  620 

irremovable,  with  colloidcontents,  691 

metastasis,  586 

mixed  proliferating,  581 

multilocular,  574 

myxoid,  771 

origin,  587 

originating  in  chronic  oophoritis,  560 
in  corpus  luteum,  560 

ossification,  586 

papillary,  580 

parvilocular,  576 

part  of,  imbedded  in  pedicle,  621 

pedicle,  584,  625 

peritonitis  caused  by,  594 

prognosis  of,  603 

proliferating,  571 

pseudo-intraligamentous,  622 

relation  to  carcinoma,  576 

retroperitoneal,  585 

Kokitanski's,  570 

rupture  of,  586,  593 

spindle-cells  in  fluid  of,  579 

suppuration  of,  586,  593 

symptoms  of,  588 

torsion  of  pedicle,  584,  593 

treatment,  603 

tubo-ovarian,  583 

unilocular,  570 

wall  of,  570,  574,  582 

with  pregnancy,  603 
tumor — 

intraligamentous,  585,  620 

oligocystic,  569 

'solid,  597,  636 

(See  Ovarian  Cyst.) 
Ovaries — 
abscess,  558 
absence,  549 
adenosarcoma,  638 

alternate  swelling  at  menstruation,  120 
anatomy,  65 
carcinoma,  639 
carcinomatous  cystoma,  639 
cirrhosis,  558 
cystocarcinoma,  639 
cysts,  567 
descent,  23 
development,  22 
diseases  of,  549 
displacement,  550 
endothelioma    (Ackermann)    639 

(Jones),  565 
excessive  growth,  549 
fibroma,  636 
fibrosarcoma,  638 
function,  74 


INDEX. 


709 


Ovaries — 

gyroma,  563 

hem  atom  a,  554 

hernia,  550 

hydrocele,  583 

hyperemia,  554 

inflammation,  557 

intermittent  hydrocele,  525 

malformations,  549 

myxosarcoma,  638 

neoplasms,  567 

neuralgia,  642 

palpation,  531 

papilloma,  637 

prolapse,  551 

rudimentary,  549 

sarcoma  of,  638 

carcinomatosum,  638 

second  ovary  in  ovariotomy,  614 

supernumerary,  120,  549 

tuberculosis,  641 

with  pedunculated  cysts,  571 
Ovariotomy,  606 

abdominal,  607 

after-treatment,  615 

causes  of  death  after,  635 

complications  during    after-treatment. 

631 
during  operation,  616,  629 

contraindications,  606 

difficulties,  616 

drainage,  629 

heinostasis,  627 

incomplete,  623 

indications,  606 

injury  of  gall-bladder,  618 
of  intestine,  617 
of  uterus,  621 

instruments,  607 

opiates,  615 

papilloma  extending  into  other  organs, 
622 

parotitis  after,  635 

preparatory  treatment,  607 

prognosis,  625 

second  ovary,  614 

shock,  631 

temperature,  632 

toilet  of  peritoneum,  627 

vaginal,  607 

Ovula  of  Naboth,  407,  410 
Ovulation,  118 
Ovisacs,  67 
Ovum.     (See  Ova.) 
Ox-gall,  174 

P. 

Pachyderm ia  of  vulva,  279 
Pachyperitonitis,  hemorrhagic,  651 


Pachysalpingitis,  525 
Pack;  hot,  187 
Packing,  vaginal,  178 
Pad,  perineal,  304 
Pain,  134 

intermenstrual,  417 
Palm se  plicatse,  49 
Palpation— 

of  abdomen,  57 

of  ureters,  167 
Papilloma — 

growing  from  ovarian  cyst  into  other 
organs,  622 

in  ovarian  cyst,  580 

of  Fallopian  tubes,  547 

of  ovary,  637 

of  uterus,  521 

of  vulva,  277 

on  outer  surface  of  myxoid  proliferat- 
ing cystoma  of  ovary,  575 

on  outer  surface  of  ovary,  581,  637 
Paquelin's  thermocautery,  182 
Parametric  connective  tissue,  56 
Parametritis,  657 
Parametrium,  56 

Parenchymatous  zone  of  ovary,  67 
Paring,  213 

Parotitis  after  ovariotomy,  635 
Parovarian  varicocele,  644 
Parovarium — 

anatomy,  74 

development,  22 
Partitioning  the  vagina,  457 
Parturition — 

pelvic  floor  during,  112 

results     in     regard    to     pelvic    floor, 

113 

Patch,  mucous,  295 
Patient,   preparation   of,  for   operations, 

196 
Pawlik,  catheterization  of  ureter,  165 

operation  for  incontinence,  379 
P£an,  position,  609 

retractor,  486 

traction-forceps,  212 

vaginal  hysterectomy,  674 
Pectiniform  septum,  38 
Pedicle  of  ovarian  cyst — 

composition,  84 

ligation,  612,  625 

torsion,  584,  593 
Pelvic — 

abscess,  665 

hysterectomy  for,  675 
opening — in  two  sittings,  667 

carcinoma,  678 

diaphragm — 
anatomy,  97 
function,  97 


710 


INDEX. 


Pelvic  floor — 

anatomy,  94 

during  parturition,  112 

entire  displaceable  portion,  110 

entire  fixed  portion,  111 

function,  111 

projection,  105 

pubic  segment,  110 

results  from  parturition,  113 

sacral  segment,  110 

sarcoma,  678 

structural  anatomy,  110 
hematoma,  655 
hemorrhage,  649 
lymphadenitis,  676 
lymphangitis,  676 
peritonitis,  657 
phlebitis,  675 
sarcoma,  678 
Pelvis — 

adhesions  in,  618 
diseases  of,  643 
hydatids,  679 
malformations  of,  643 
three  spaces  of,  94 
Penis  captivus,  355 
Pepsin,  225 
Percussion,  158 
Perimetric  inflammation,-  657 
Perimetritis,  657 
Perineal — 
body,  104 

cystic  hygroma,  325 
hysterectomy,  520 
pad,  304 
region,  99 
Perineorrhaphy — 
after-treatment,  322 
Cleveland's,  319 
Emmet's,  316 
for  retroflexion,  348 
Garrigues',  311 
intermediate,  307 
Outerbridge's,  318 
preparation  for,  322 
primary,  304 
secondary,  307 
Tail's,  307 
Perineotomy — 
transverse,  668 
vertical,  667 
Perineum — 

complete  laceration,  305 

development,  31 

diseases,  301 

incomplete  laceration,  303 

injuries,  301 

needle,  217 

old  lacerations,  307 


Perineum — 

recent  lacerations,  301 
Perioophoritis,  557 
Perisalpingitis,  525 
Peritoneum — 

function,  92 

gelatinous  disease,  587 

pelvic,  90 

pseudomyxoma,  587 

taken  for  ovarian  cvst-wall,  615 

toilet,  627 
Peritonitis — 

diagnosis  from  ovarian  cyst,  596 

pelvic,  657 

septic,  633 

with  ovarian  cyst,  594 
Pessary — 

after  ventrofixation,  453 

Breisky's,  456 

Emmet's,  446 

Fowler's,  447 

Gariel's,  456 

Geh  rung's,  435 

general  remarks,  436 

Hewitt's  cradle,  435 

Hodge's,  446 

Mayer's,  456 

retrotiexion,  446 

stem-,  441 

Thomas's  anteversion,  185,  435 
retroflexion,  553 

vaginal,  435 

Vienna,  435 

whalebone,  447 
Petit's  triangle.  666 
Petzer,  catheter,  486 
Phagedena,  292 
Phantom  tumor,  602 
Phlebitis- 
after  ovariotomy,  635 

pelvic,  675 
Physiology,  114 
Physometra,  125,  392,  421,  598 
Pilimiction,  582 
Pills- 
aloes  and  iron,  225 

antidysmenorrheic,  243 

Chian  turpentine,  515 

conium,  243 

emmenagogue,  240 
Pinhole  os,  421 
Pinworms,  273 
Pistol,  E.  Martin's,  171 
Platysma,  57 
Pledgets,  vaginal,  178 
Plicae  palmate,  49 
Plombieres,  188 
Plug,  vaginal,  179,  330 
Poles,  qualities  of,  233 


INDEX. 


711 


Polk,  needle  for  hysterectomy,  487 

shortening  of  round  ligaments,  453 
Polypus — 

fibrinons,  468 

fibroid,  uterine,  469 
vaginal,  360 

glandular,  467 

hollow,  463,  466 

intermittent,  473 

mucous,  of  uterus,  408,  467 
vaginal,  361 

myxomatous,  467 
Position,  136 

breech-back,  137,  197,  198,  368 

dorsal,  136 

erect,  138 

genupectoral,  138 

high  pelvic.     (See  Trendelenburg's.) 

Simon's,  197,  368 

Sims's,  137 

Trendelenburg's,  138,  195 

ventral,  139 

Posterior  commissure,  36 
Postural  treatment  of  retroflexion,  447 
Potain,  aspirator,  159 
Potassa,  269,  413 
Pouch — 

Douglas's,  91 

obturator,  91 

para-uterine,  91 

paravesical,  91 

recto-abdominal,  91 

recto-uterine,  91 

utero-abdominal,  91 

vesico-abdominal,  91 

vesico-uterine,  91 
Poultice,  187 
Powders — 

headache,  249 

phenacetine  compound,  249 
Pozzi,  injecting  cysts  with  spermaceti,  290 

injury  to  ureters,  619 

operation    for    ureterovaginal    fistula, 
375 

ventrofixation,  452 
Pratt,  hysterectomy,  491 
Precocity,  387 
Pregnancy — 

diagnosis  from  ovarian  cyst,  589 

in  relation  to  uterine  fibroids,  500 

operations  during,  192 

with  cancerous  uterus,  519 

with  ovarian  cyst,  603 
Pregnant  cancerous  uterus  removed  by 

vaginal  hysterectomy,  519 
Prepuce,  37 

adherent,  257 
Pressure — 

as  hemostatic,  627 


Pressure — 

-forceps,  184,  214,  485 

symptoms,  474 
Priessnitz's  compress,  187 
Primary  follicles,  28 
Primordial  ova,  28 
Probe,  153 

Procidentia  of  uterus,  454 
Progressive  atrophy  of  nymphse,  288 
Prolapse- 
acute,  of  uterus,  454 

Brandt's  method,  456 

chronic,  455 

complete,  454 

incomplete,  453 

Lefort's  operation,  457 

of  anterior  wall  of  vagina,  335 

of  intestine  into  deep  Douglas'  pouch, 
335 

of  ovaries,  551 

of  posterior  wall  of  vagina,  340 

of  urethra,  296 

of  uterus,  454 

of  vagina,  340 

operations,  457 
Prolapsus  of  uterus,  454 
Proliferating  cyst,  571 
Pruritus,  272 

Pseudohermaphrodism,  259 
Pseudo-intraligamentous  tumors,  622 
Pseudomyxoma  of  peritoneum,  587 
Puberty,  114 

different  from  nubility,  114 
Puncture,  explorative,  .595 
Pus,  inspissation  of,  534 
Pyocolpos,  326 

lateral,  333 

Pyometra,  326,  392,  421 
Pyosalpinx,  525,  543,  597 

saccata,  525 
Pyroinania,  247 

R. 

Raphe— 

ano-coccygea,  97 

perineal.  101 

Receptaculum  seminis,  63 
Rectal- 
alimentation,  225 

ampulla,  85 

speculum,  150 
Rectocele,  340 

Emmet's  operation,  316 
Rectum — 

anatomy,  83 

function,  89 

Reese,  artificial  leech,  186 
Regions — 

abdominal,  113 


712 


INDEX. 


Regions — 
anal,  99 
perineal,  99 
urogenital,  99 
Repositor — 
Aveling's,  464 
Byrne's,  465 
White's,  465 
for  inversion,  464 
for  retroflexion,  446 
Resolution,  226 
Resolvents,  226 
Respiration,  artificial,  207 
Rest-cure,  225 

Retractor  muscles  of  uterus,  55 
Retractor-* 
Engelmann's,  211 
Plan's,  486 
Schroeder's,  211 
vaginal,  211,  486 
Retroflexed  gravid  uterus,  597 
Retroflexion,  443 
Retro-ovarian  shelf,  91 
Retroposition,  394 
Retroversion,  442 
Reverdin,    apparatus    for    lifting    large 

tumors,  496 

Reviving  from  anesthesia,  207,  210 
Rheophores,  232 
Rheostat,  232 
Richardson's  bellows,  207 
Rima  pudendi,  36,  43 
Robb,  leg-holder,  198 
Rodent  ulcer,  508 

different    from    the    corroding    ulcer, 

512 

Rokitanski's  tumor,  570 
Roof  of  vagina,  42 
Room,  operating-,  193 
Rosenmiiller's  organ,  22 
Round  ligament — 
anatomy,  58 
diseases,  648 
fibroma,  264 
function,  50,  60 
hematoma,  263 
shortening,  448,  453 
tumors  connected  with  extrapelvic 

portion,  262 
Rubber — 

bag  for  injecting  bladder,  176 
cushions  for  operations — 
Kelly's,  194 
Marcy's,  194 

ligatures,  preservation  of,  207 
Rudimentary  horn  of  uterus,  389 
Rugfe  of  vagina,  43 
Rupture  of  ovarian  cyst,  586,  593 
Ruptures  (hernise),  260 


S. 

Sacral  hysterectomy,  519 
Sacrotomy,  668 
Sacro-uterine  ligament,  55 

diseases  of,  648 
Salpingitis,  525 

acute  catarrhal,  525 
purulent,  525 

chronic  interstitial,  525 

conservative  treatment  of,  533 

cystic,  525,  541 

infectious,  525 

interstitial,  526 

isthmica  nodosa,  525 

mural,  525 

non-infectious,  525 

parenchymatous,  525 

profluent,  525 
Salpingo-oophorectomy,  534 

abdominal,  535 

for  anteflexion,  442 

for  hemorrhagic  endometritis,  420 

mortality,  538 

results,  539 

vaginal,  540 

with  ventrofixation,  453 
Salt,  solution  of,  502 
Sand-bodies,  581 
Sarcoma — 

carcinomatosum  of  ovary,  638 

decidual,  506 

of  Fallopian  tube,  547 

of  ovary,  638 

of  pelvis,  678 

of  uterus.  503 

of  vagina,  561 

of  vulva,  283 

Scarification  of  vaginal  portion,  186 
Scarificator,  Buttle's,  186 
Schede,  operation  for  ureterovaginal  fis- 
tula, 374 

Schimmelbusch,  sterilization-box,  202 
Schroeder,     needle     for     hysterectomy, 
487 

operation  for  vaginal  cyst,  359 

repair  of  intestine,  495 

vaginal  retractor,  211 
Schuchardt,  hysterectomy,  520 
Schultze,  disinfection  of  laminaria  tents, 
154 

method  of  tearing  adhesions  of  ovary, 

553 

of  uterus,  450 
Scirrhus  of  vulva,  283 
Scissors,  213 

Bozeman's,  479 

Kiichenmeister's,  422 
Searcher,  ureteral,  165 


INDEX. 


713 


Section,  vaginal,  compared  with  abdomi- 
nal, 493,  540 
Sedatives,  226 
Segmental  vesicles,  21 
Segond,  speculum,  484 

vaginal  hysterectomy,  483 
Septicemia,  502,  633 
Septum— 

pectiniform,  38 

retrohymenale,  328  , 

transverse  perineal,  101 
Serrefines,  303 
Shelf,  retro-ovarian,  91 
Shock,  501,  631 
Shortening  of  round  ligament — 

extraperitoneal,  448 

intraperitoneal,  453 

vaginal,  453 
Shouldering,  219 
Silk,  201 
Silkworm  gut,  204 
Silver  wire,  204,  217 
Simon,  cone-mantle-shaped   excision   of 
cervical  portion,  419 

curette,  153 

intestinal  examination,  142 

operation  for  fistula,  368 

position,  368 

Simpson,  J.  Y.,  metrotome,  422 
Sims,  Marion,  catheter,  367 

discission   of  posterior   lip   of  cervix, 
441 

needle-holder,  215 

operation  for  anteversion,  437 
for  cystocele,  336 
for  rectovaginal  fistula,  366 
for  urinary  fistula,  366 

speculum,  145 

sponge-holder,  213 

suture-shield,  218 

uterine  knife,  422 
Sinus  copularis,  30 
Sinuses  of  Morgagni,  87 
Skene's  glands,  76 
Smith,  cautery-clamp,  612 
Smith,  Greig,  ligature-box,  202 
Sodium  sulphate,  228 
Solution — 

borosalicylic,  206 

ergotine,  480 

Labarraque's,  668 

Monsel's,  499,  628 

normal  salt,  502 

sclerotinic  acid,  480 

sodium  carbonate,  199 

tannin-iodoform,  412 

Thiersch's,  206 

Villate's,  668 
Solutions,  antiseptic,  205 


Souffle,  uterine,  158 
Sound,  uterine,  152 
Space — 

subcutaneous,  of  pelvis,  94 

subperitoneal,  of  pelvis,  94 
Spanish-fly  blister,  188 
!  Spectators,  196 
I  Speculum — 

Ashton's,  150 

bath-,  187 

bivalve,  145 

bladder-,  163 

Bozeman's,  368 

Brewer's,  144 

Barrage's,  150 

cervical,  150 

Cusco's,  144 

Ehrich's,  148 

Fergusson's,  144 

Folsom-Skene's,  151 

Garrigues',  211 

Jackson's,  150 

Kelly's  163 

Kelsey's,  150 

Munde's,  147 

Mitchell's,  147 

pi  uri  valve,  144 

rectal,  150 

self-holding,  147 

Segond' s,  484 

Sims's,  145 

tubuliform,  144 

univalve,  145 

urethral,  150 

vaginal,  144 
Sphincter — 

ani,  how  to  unite  broken,  320 

muscles  of  urethra,  76 

of  rectum,  third,  87 
Spina  bifida,  601 
Spiritus  glonoini.  210 
Spleen — 

adhesions,  618 

cyst,  601 

tumor,  601 

Sponge  taken  for  carcinoma,  511 
Sponges,  200 
Sponge-holder,  213 
Sponging,  222 
Spontaneous    opening    of    wound    after 

ovariotomy,  634 
Spoon,  sharp,  153 
Spoon-saw,  478 
Springs,  mineral,  188 
Staffordshire  knot,  536 
Steam  as  disinfectant,  195 

as  hemostatic,  618 
Stearate  of  zinc,  630 
Stem-pessary,  441,  447 


714 


INDEX. 


Stenosis — 

of  cervical  canal,  242,  394,  421 
acquired,  421 
congenital,  421 

of  vagina,  328 
Sterility,  682 

after  double  ovariotomy,  635 

in  the  female,  683 

in  the  male,  682 

primary,  683 

secondary,  683 
Sterilization  of  catgut,  202 
Sterilizer,  199,  202 

Arnold's,  201 

Schimmelbusch's,  202 
Stimulants,  210,  224 
Stitch,  cobbler's,  614,  627 
Stomach,  dilatation  of,  601 
Stramonium  pills,  243 
Structureless  membrane  of  Graafian  folli- 
cle, 69 
Strychnine — 

in  collapse,  210 

mixture,  226 

pills,  240 
Stupe,  187 
Styptics,  182,  602 
Subinvolution  of  uterus,  416 
Summit  of  bladder,  78 
Superfetation,  391 
Superinvolution  of  uterus,  431 
Supporter — 

abdominal,  190 

uterine,  456 
Suppositories — 

with  iodoform,  324,  407 

with  morphine,  324 

with  opium,  226 

Suppuration  of  ovarian  cyst,  586 
Supravaginal  amputation  compared  with 
total  extirpation  of  uterus,  498 
Suspensio  uteri,  452 
Suture,  217 

buried  catgut,  314,  316 

button-,  368 

chain-,  222,  625 

Cleveland's,  319 

cobbler's  stitch,  614,  627    ^ 

continuous,  220 

Czerny-Lembert's,  617 

for  fecal  fistula,  383 

for  hemostasis,  184 

for  inversion,  465 

for  urinary  fistula,  365 

forming  nucleus  of  stone,  371 

Glover's,  614 

Halsted's,  494 

horsehair,  204 

how  to  remove,  222 


Suture — 

interrupted,  220 

kangaroo  tendon,  204 

Lauenstein's,  316 

Marcy's,  494 

material,  200,  217,  304 

mattress-,  184 

quilled,  184,  220 

removal  of,  222 

secondary  infection  of,  217 

-shield,  219 

shouldering,  219 

silk,  201,  217 

silkworm  gut,  204 

silver  wire,  204,  218 

sterile,  200 

subcuticular,  493 

submucous,  316 

tier-,  221 

twisting,  220 

Swedish  movement  cure,  191 
Sylvester's  artificial  respiration,  207 
Syphilis,  293 

indurating  edema,  285 

initial  lesion,  293 

secondary,  295 

tertiary,  296 
Syringe — 

Braun's,  172 

bulb-nnd-valve,  171 

Davidson's,  171 

for  bladder,  175,  176 

fountain,  171 

Frost's,  673 

uterine,  172 

T. 

Table— 

Daggett's,  135 

examining-,  135 

operating-.     (See  Operating-table.} 
Tail,  flap-splitting  operation  for  perineal 
laceration,  307 

operation  for  fecal  fistula,  384,  385 
for  urinary  fistula,  369 

salpingo-oophorectomy,  535 

shortening  of  round  ligaments,  453 

"Tait's  operation,"  535 
Tampon — 

abdominal,  181 

vaginal,  178 
Tamponade,  177 

of  uterus,  180 
Tannin — 

glycerite,  178 

solution  with  iodoform,  418 
Tape-carrier,  478 
Tapping,  188,  604 


INDEX. 


715 


Tate,  inversion,  475 

Taylor,   I.   E.,  operation  for  rectolabial 

fistula,  382 

Temperature  after  ovariotomy,  632 
Tenaculum,  212 

Emmet's,  212 

-forceps,  213 
Tendinous  arch,  94 
Tents,  154 
Tent-carrier,  155 
Tetanus,  503,  635 
Thermal  galvanocauterization  for  cancer 

of  uterus,  516,  517 
Thermocauterectomy  of  uterus,  518 
Thermocautery,  182 
Thiersch's  solution,  206 
Thirst,  223 
Thomas,  anteversion  pessary,  435 

classification  of  anteflexion,  438 

enucleation  of  uterine  fibroids,  481 

inversion,  464,  465 

operation  for  vaginismus,  357 

retroflexion  pessary,  553 

stem-pessary,  441 

spoon-saw,  478 

Thompson,  bladder-syringe,  176 
Thrombosis,  502 
Thrombus — 

of  vagina,  341 

of  vulva,  276 
Thymol,  206 
Tincture  of  iodine — 
in  ovariotomy,  628 
on  the  skin,  148 
in  the  vagina,  170 
Tissue-forceps,  213 
Toilet  of  peritoneum,  627 
Tongue-forceps,  209 
Tonics,  226 
Trachelorrhaphy,  399 

for  retroflexion,  448 
Trachelotomy,  422 
Traction,  for  removing  uterine  fibroids, 

482 

Transfusion,  502 

Travelling,  cure  for  sterility,  586 
Treatment — 

electric,  229 

external,  170 

in  general,  168 

internal,  224 
•    preventive,  168 

Trendelenburg,     operation     for     fistula, 
369 

position,  138 
anesthesia  in,  209 
apparatus  for,  139,  195 
Trichiasis,  272 
Trichomonas  vaginalis,  344 


Trigone — 

Lieutaud's,  78 

Pawlik's,  165 
Tripperfaden,  531 
Trocar — 

Emmet's,  611 

Kelly's,  611 

vaginal,  189 

Warren's,  605 
Tubercle  of  vagina,  43 
Tuberculosis — 

of  Fallopian  tube,  547 

of  ovary,  o'41 

of  peritoneum,  599 

of  uterus,  522 

of  vagina,  362 

of  vulva,  288 
Tubes— 

double-current  uterine,  173 

drainage-,  185 

Fallopian,  62,  548 

single-current  uterine,  173 
Tubo-ovarian  cyst,  583 
Tumeur  fluxionnaire,  417 
Tumor — 

fibroid,  of  uterus,  468 

of  abdominal  wall,  601 

of  broad  ligament,  648 

of  round  ligament,  262 

of  spleen,  601 

of  vulva,  275. 

(See  Cancer,  Cyst,   Carcinoma,  Fi- 
broid, Sarcoma,  etc.) 

oligocystic,  569 

oozing,  278 

painful,  of  urethra,  282 

phantom,  602 

Rokitanski's,  570 

solid  ovarian,  636 

vascular,  of  urethra,  282 
Tunica — 

fibrosa  of  Graafian  follicle,  68 

propria  of  Graafian  follicle,  68 
Turns,  115 

Turpentine,  Chian,  515 
Tuttle,  fibroma  molluscum,  281 
Tympanites,  174,  602,  632 

U. 

Ulcer- 
corroding,  424,  512 

of  cervix,  424 

rodent,  508 

simple,  424 

tuberculous,  288,  362,  424 

venereal,  291,  293 
Urachus,  31,  80 

persistent,  495,  616 


716 


INDEX. 


Ureter — 
anatomy,  81 

at  base  of  intraligamentous  tumors,  622 
catherization,  165 
course  during  pregnancy,  82 
examination,  161 
function,  83 
implantation,  375 
injury,  371,  373,  537,  618 
ligation,  371,  503,  537 
opening  into  vagina,  334 
palpation,  167 
Ureterocystostomy,  375 
extraperitoneal,  375 
intraperitoneal,  375 
Urethra — 
anatomy,  75 
atresia,  372 
caruncle,  282 
dilatation  of,  142 
ducts,  76 

inflammation  of,  270 
function,  77 

irritable  vascular  excrescence,  282 
painful  tumor,  282 
prolapse,  296 
suprapubic,  378 
vascular  tumor,  282 
Urethral — 
ducts,  76 

inflammation  of,  270 
speculum,  150 
Urinals,  378 
Bozeman's,  375 
Jay's,  379 

Urinary  analysis,  160 
Urine — 

alkaline,  355 

examination  with  regard  to  operations, 

196 

suppression  of,  632 
Urogenital  region,  99 

sinus,  20,  31  • 

persistent,  334 

Uterine  appendages  of  the  other  side — 
in  ovariotomy,  614 
when  one  set  is  removed,  537 
artery — 

aneurysm,  643 
during  pregnancy,  61 
ligature  of,  182 
cancer,  503 

radical  treatment,  516 
carcinoma,  507 
fibrocyst,  473 

treatment,  503 
fibroid — 

abdominal  enucleation,  498 
apparatus  for  lifting,  496 


Uterine  fibroid — 

cervical,  468 

changes,  473 

combined  with  pregnancy,  500 

corporeal,  468 

curetting,  481 

galvanochemical  cauterization,  480 

hypodermic  injection  of  ergot,  480 

indications  for  operations,  503 

in  negro  race,  474 

interstitial,  470 

intramural,  470 

mortality  of  operations,  500 

multiple,  472 

oophorectomy,  483 

pedunculated,  470 

sessile,  470 

single,  472 

sloughing,  500 

submucous,  470 

subperitoneal,  470 

supravaginal  amputation,  496 

traction  method,  482 

vaginal  enucleation,  481.     (See 

Uterus.) 

Uterotractor,  518 
Uterus — 

absence  of,  387 

acollis,  393 

acquired  atrophy,  431 

adenoma,  467 

anatomy,  47 

anteflex'ion,  394,  438 

anteposition,  394 

ante  version,  433 

apoplexy  of,  125 

arrest  of  development,  387 

artificial  prolapse,  143 

atresia,  391,  420 

bicameratus  vetularum,  125 

bicornis,  390 

bilocularis,  390 

bimanual  replacement,  445 

cancer,  503 

carcinoma,  507 

of  body,  508 

of  cervix,  508 

of  vaginal  portion,  507 
catarrh,  410 
cavernous  angioma,  468 
cervical  carcinoma,  508 
closure,  420 

congenitally  atrophic,  393 
cysts,  467 
cystosarcoma,  504 
descent,  454 
development,  31 

excessive,  386 
didelpliys,  388 


INDEX. 


Ill 


Uterus- 
digital  replacement,  446 
dilatation,  154 
diseases,  387 
displacement,  433 
duplex  separatus,  388 
elevation,  460 
enchondroma,  522 
erosions,  408,  413,  424,  513 
excessive  development,  387 
extirpation,  483 
fetal,  392 

fibrocysts,  473,  598 
fibroid,  469 

tumor,  469 
fibroma,  469 
fibromyoma,  469 
foreign  bodies,  403 
function,  62 
gangrene,  432 
hernia,  394,  466 
horns,  31 
hypertrophv,  424 
infantile,  392 
inflammation,  403 
injuries,  394 
inversion,  460 
irregular  development,  394 
lateroflexion,  394,  454 
lateroposition,  394 
latero version,  394,  454 
ligaments,  54 
male,  30 

malformations,  387 
malposition,  394 
myofibroma,  469 
myoma,  469 
myxoma,  467 
myxosarcoma,  504 
neoplasms,  467 
neuralgia,  432 
obliquity,  394 
papilloma,  521 
parvicollis,  393 
polypus,  467 

glandular,  467 

hollow,  463,  466 

mucous,  467 

myxomatous,  467 
procidentia,  454 
prolapse,  454 
prolapsus,  454 
pubescent,  393 
repositors,  446 
retractor  muscles,  55 
retroflexion,  443 
retroposition,  394 
retroversion,  442 
rudimentary,  388 


Uterus — • 

rudimentary  horn,  389 

sarcoma,  503 

senile  atrophy,  431 

septus,  390 

severance  of  adhesions,  453 

shape  and  position,  51 

subinvolution,  416 

subseptus,  390 

superin volution,  431 

supravaginal    amputation,    496.     (See 

Hysterectomy.) 
suspension  of,  452 
tamponade,  180 
thermocauterectomy,  518 
total  extirpation,  483 

compared  with  supravaginal  ampu- 

tion,  498 
tuberculosis,  522 
tumeur  fluxionnaire,  417 
unicornis,  389 
vaginofixation,  450 
ventrofixation,  452 
wounded  in  ovariotomy,  618,  621 

V. 

Vagina — 

anatomy,  41 

atresia,  328,  333 

blind  canals,  333 

carcinoma,  361 

cicatrices,  353 

cysts,  358 

development,  31 

diseases  of,  326 

double,  332 

entrance,  43 

erysipelas,  353 

extirpation,  partial  or  total,  in  carci- 
noma of  uterus,  518 

faulty  communications,  333 

fibroid  polypus,  359 
tumor,  359 

fibroma,  359 

fibromyoma.  359 

foreign  bodies,  342 

function,  45 

gangrene,  352 

glass  plug,  330 

hematoma,  342 

how  to  keep  open  after  atresia  opera- 
tion, 330,  331 

incision,  450,  484,  487,  533,  666 

injuries,  341 

inversion,  340 

laceration  of  entrance,  305 

malformations,  326,  328 

mucous  polypus,  361 


718 


INDEX. 


Vagina — 

myofibroma,  359 

narrowness,  329 

neoplasms,  358 

partitioning,  457 

prolapse,  340 

of  anterior  wall,  335 
of  posterior  wall,  340 

sarcoma,  361 

stenosis,  328 

tamponade,  179 

thrombus,  341 

tuberculosis,  362 
Vaginal — 

enterocele,  334 
case  of,  334 

glass  plug,  185 

hernia,  334 

hysterectomy,  limits,  490 

portion — 
anatomy,  47 
development,  32 

subinvolution,  416 

speculum,  144 
Vaginismus,  328,  355 

deep,  355 

superficial,  355 
Vaginitis,  343 

acute,  343 

adhesive,  344 

catarrh  al.  344 

chronic,  343 

diagnosis  between  simple  and  gonor- 
rheal,  346 

diphtheritic,  350 

dissecting,  351 

due  to  burrowing  pus  from  pelvic  ab- 
scess, 352 

dysenteric,  351 

emphysematous,  349 

epithelial,  348 

exfoliative,  348 

exudative,  350 

follicular,  344 

glandular.  344 

gonorrheal,  346 

granular,  344 

mycotic,  349 

phlegmonous,  351 

primary,  343 

secondary,  343 

simple,  344 

Vaginofixation  of  retroflexed  uterus,  450 
Valves — 

Houston's,  87 

of  rectum,  87 
Varicocele — 

of  broad  ligament,  644 

parovarian,  644 


Vascular  zone  of  ovary,  67 
Vegetations  of  vulva,  277 
Veins — 

of  perineal  region,  108 

varicose,  of  vulva,  276 
Venereal  diseases,  291 
Ventrofixation  of  uterus,  452 
Vesicula  prostatica,  30 
Vessels  needed  for  operations,  198 
Vestibule — 

anatomy,  39 

development,  32 

function,  40 

Vestibulovaginal  bulb,  39 
Vignard,  operation  for  fecal  fistula,  384 
Villate,  solution,  668 
Virgins,  examination  of,  156 
Vitelline  membrane,  70 
Vitellus,  70 
Volsella,  212 

Vomiting,  192,  211,  225,  226,  631 
Vuillet,  method  of  dilatation,  156 
Vulva — 

absence  of,  255 

anatomy,  36 

angioma,  282 

atrophic  carcinoma,  283 

cancer,  283 

carcinoma,  283 

chronic  infiltration,  285 
inflammation,  285 
ulceration,  285 

cysts,  283 

development,  33 

diseases  of,  255 

elephantiasis,  279 

epithelial  coalescence,  258 

epithelioma,  283 

exanthematous  diseases,  271 

fibroma,  280 

gangrene,  270 

garrulity,  323 

hematoma,  276 

hyperesthesia,  275 

hyperplasia,  275,  285 

injuries,  265 

kraurosis,  288 

lipoma,  281 

lupus,  285 

malformations,  255 

medullary  carcinoma,  283 

melanosarcoma,  283 

myoma,  281 

myxoma,  281 

neoplasms,  277 

neuroma,  282 

oozing  tumor,  278 

pnchydermia,  279 

papilloma,  277 


INDEX. 


719 


Vulva — 

pruritus,  272 

sarcoma,  283 

scirrhus,  283 

thrombus,  276 

tuberculosis,  288 

tumors,  275 

varicose  veins,  276 

vegetations,  277 

warts,  277 
Vulvitis,  266 
Vulvovaginal  gland — 

abscess,  290 

anatomy,  40 

catarrh^  289 

cysts,  289 

diseases  of,  289 
Vulvovaginitis  in  children,  352 

W. 

Walcher,  operation  for  fistula,  370 
Wallich,  chain-suture,  625 
Warren,  trocar,  605 
Warts  of  vulva,  277 


Water,  hot,   182 

Watkins,  operation  for  cystocele,  338 
Wells,  pedicle-forceps,  612 
White,  Jas.  P.,  inversion,  465 
White  line — 
at  anus,  87 
of  labia  minora,  37 
Whites,  250 

Wiley,  Gill,  shortening  of  round  liga- 
ments, 453 
Wire-twister,  219 
Wolffian— 

body,  20 

duct,  19 

Woman's  dartos,  37 
Womb,  falling  of,  454 


Xenomenia,  241 


X. 


Z. 


Zona  pellucida,  70 
Zuckerkandl,  hysterectomy,  520 


ILLUSTRATIONS. 


DEVELOPMENT. 

FIG.  PAGE 

1.  Wolffian  Ducts 19 

2.  Urogenital  Sinus ;   .    .  20 

3.  Wolffian  Bodies 21 

4.  Beginning  of  the  Bound  Ligament 22 

5.  Lateral  Canals  of  Wolffian  Body 23 

6.  Transformation  of  the  Wolffian  Body  in  the  Male 24 

7.  Transformation  of  the  Wolffian  Body  in  the  Female 24 

8.  Transverse  Section  of  Ovary  of  Human  Embryo  three  months  old    ....   24 

9.  Transverse  Section  through  Eegion  of  Ovary  of  Human  Embryo  five  months 

old 25 

10.  Ovary  of  Human  Fetus  ten  to  eleven  weeks  old 25 

11.  Part  of  Ovary  of  Human  Fetus  sixteen  weeks  old 26 

12.  Part  of  Ovary  of  Human  Fetus  twenty-eight  weeks  old 26 

13.  Part  of  Ovary  of  Human  Fetus  thirty-six  weeks  old '26 

14.  Part  of  Ovary  of  a  Girl  three  days  old 27 

15.  Perpendicular  Section  of  Ovary  of  a  Bitch  six  months  old,  showing  tubes  with 

primordial  ova 28 

16.  Graafian  Follicles  of  New-born  Girl 28 

17.  Graafian  Follicle  of  a  Girl  seven  months  old 29 

18.  Primordial  Ova  undergoing  Division 29 

19.  Transverse  Section  of  Embryo  of  Eabbit  fourteen  days  old,  showing  the  for- 

mation of  the  Miillerian  Ducts 30 

20.  Transverse  Section  through  the  Genital  Cord  of  Embryo  of  Cow 31 

21.  Ovaries,  Tubes,  and  Horned  Uterus  of  Human  Embryo  in  the  tenth  week  .    .   31 

22.  Entrails  of  Abdomen  and  Pelvis  of  a  Female  Human  Embryo  five  months  old    32 

23.  24,  25.     Formation  of  Anus,  Cloaca,  and  Urogenital  Sinus 32 

26.  Urogenital  Sinus  and  Organs  opening  into  it 33 

27.  Development  of  the  External  Sexual  Organs  in  the  Male  and  the  Female  .    .  34 

ANATOMY. 

28.  External  Genitals 36 

29.  Hottentot  Apron  (colored  plate  ) 37 

30.  Front  View  of  Perineal  Septum,  showing  entire  Clitoris 38 

31.  Nerves  of  Pelvic  Viscera  (colored  plate) 39 

32.  The  Vestibulovaginal  Bulbs 40 

33.  The  Vulvovaginal  Gland 41 

34.  Sagittal  Section  of  Pelvis     42 

35.  Horizontal  Section  of  the  Soft  Parts  in  the  Inferior  Strait  of  the  Pelvis  ...   43 

46  721 


722  ILLUSTRATIONS. 

FIO.  PAGE 

36.  Microscopical  View  of  Longitudinal  Section  of  the  Vagina  of  a  Girl  twenty- 

four  years  old 44 

37.  Transverse  Section  of  the  Same 44 

38.  The  Arteries  of  the  Uterus,  the  Ovaries,  and  the  Vagina  (colored  plate)  ...  44 

39.  The  Venous  Plexuses  of  the  Vagina  and  Vulva,  as  seen  in  mesial  section    .   .   45 

40.  Hymen  with  Linear  Opening 46 

41.  Annular  Hymen 46 

42.  Crescent-shaped  Hymen 47 

43.  Indented  Hymen 47 

44.  Virgin  Uterus 48 

45.  The  Utricular  Glands 50 

46.  Section  of  the  Mucous  Membrane  of  the  Uterus,  parallel  to  the  surface   ...   51 

47.  Fiber  of  Endometrium,  showing  different  degrees  of  corpuscular  development  52 
46.    Uterine  Epithelial  Cells 52 

49.  Mesial  Section  of  the  Pelvis  of  a  Girl  seventeen  years  old 53 

50.  Diagram  of  Mesial  Section  of  the  Pelvis  of  a  Living  Woman 54 

51.  Endometrium  of  a  Woman  sixty  years  old 54 

52.  Diagram  of  the  Ligaments  of  the  Uterus 55 

53.  The  Pelvic  Viscera,  seen  from  above 56 

54.  The  Eight  Wall  of  the  Pelvis,  showing  insertion  of  the  broad  ligament   ...  57 

55.  The  Vessels  of  the  Vagina  and  the  Internal  Genitals  in  their  relation  to  the 

superficial  muscular  structures 58 

56.  The  Uterine  Artery  in  its  Belation  to  the  Ureter 60 

57.  The  Uterine  Veins  and  the  Ureter 61 

58.  Fallopian  Tube,  Ovary,  and  Parovarium 62 

59.  Fallopian  Tube  laid  open 63 

60.  Tube  and  Ovary  of  a  Woman  who  died  during  Menstruation 65 

6L    Ovary  and  Tube  of  Girl  nineteen  years  old 66 

62.  Ovary  and  Tube  of  Girl  twenty-four  years  old 67 

63.  Section  of  Ovary  of  Cat 68 

64.  Part  of  the  Same,  more  highly  magnified 69 

65.  Diagram  of  Zones  in  Human  Ovary 69 

66.  Graafian  Follicle  of  Adult  Woman 70 

67.  Ovum  of  Babbit 71 

68.  Microscopical  Structure  of  Corpus  Luteum  of  Pregnancy  ten  to  twelve  days 

after  rupture      72 

69.  Corpus  Luteum  of  Woman  two  days  after  menstruation  (colored  plate)  ...   73 

70.  Corpus  Luteum  of  Woman  twenty  days  after  menstruation  (colored  plate)  .    .   73 

71.  Cicatrice  of  Corpus  Luteum  nine  days  after  menstruation  (colored  plate)    .    .   73 

72.  Corpus  Luteum  at  term  of  pregnancy  (colored  plate) 73 

73.  False  Corpus  Luteum  (colored  plate) 73 

74.  Normal  Menstrual  Body 73 

75.  Ovary  of  Woman  filled  with  Yellow  Masses 75 

76.  Ovary  of  Woman  with  Cystic  Corpus  Luteum  and  Numerous  spread  Yellow 

Masses 76 

77.  Ovary  of  Woman  with  Cystic  Corpus  Luteum  and  Numerous  Yellow  Masses 

with  Bemnant  of  Central  Cavity 76 

78.  Parovarium   .7 77 

79.  Urethral  Ducts  (Skene's  glands) 78 

80.  Uterus,  Ureters,  Bladder,  and  Upper  Part  of  Vagina 79 


ILLUSTRATIONS.  723 

FIG-  PAGE 

81.  Superficial  Layer  of  Bladder  Epithelium 80 

82.  Deep  Layers  of  Bladder  Epithelium 80 

93.  The  Course  of  the  Ureters 82 

84.  Epithelium  of  Pelvis  of  Kidney      , 83 

85.  The  Eectum  inflated  with  Air 84 

86.  Vertical  Section  of  lower  end  of  Eectum 85 

87.  Muscles  of  Perineum 86 

88.  Muscular  Coat  of  Rectum 88 

89.  Mesial  Section  of  Peritoneum  with  Empty  Bladder 89 

90.  Mesial  Section  of  Peritoneum  with  Full  Bladder 90 

91.  Position  of  Viscera  at  the  Pelvic  Brim 92 

92.  Coronal  Section  of  Pelvic  Cavity 93 

93.  The  Pelvic  Fascia 95 

94.  Levator  Ani,  seen  from  below 96 

95.  Side  View  of  Levator  Ani 98 

96.  Pelvic  Floor  in  mesial  section      99 

97.  Transverse  Section  of  Pelvis  through  Axis  of  Vagina ...   100 

98.  The  Muscles  of  the  Perineum     102 

99.  Sagittal  Section  of  Perineal  Body 105 

100.  Superficial  Structures  of  the  Female  Perineum 106 

101.  Deep  Structures  of  the  Female  Perineum 107 

102.  Horizontal  Section  of  Pelvis Ill 

103.  Coronal  Section  of  Body 112 

PHYSIOLOGY. 

104.  Uterus  during  Menstruation        116 

105.  Endometrium  of  Menstruating  Woman 117 

106.  Fusion  of  Spermatozoid  and  Ovum 122 

107.  Fertilized  Ova  of  Echinus 122 

EXAMINATION. 

108.  Daggett's  Table 135 

109.  Dorsal  Position •   136 

110.  Sims's  Position     ....   137 

111.  Genupectoral  Position 138 

112.  Trendelenburg's  Position .139 

113.  Combined  Vaginal  and  Abdominal  Examination .141 

114.  Simon's  Urethral  Dilators .143 

115.  Fergnsson's  Speculum 

116.  Brewer's  Speculum     

117.  Sims's  Speculum 

118.  Introduction  of  Sims's  Speculum 

119.  Sims's  Depressor 

120.  Hunter's  Depressor 

121.  Munde's  Speculum 

122.  Mitchell's  Speculum 

123.  Ehrich's  Speculum 

124.  Garrignes'  Depressor 

125.  Bozeman's  Dressing-forceps 


724  ILLUSTRATIONS. 

FIG.  PAGE 

126.  Barrage's  Cervical  Speculum 150 

127.  Ashton's  Eectal  Speculum 150 

128.  Kelsoy's  Kectal  Speculum 150 

129.  Jackson's  Urethral  Speculum 151 

130.  Folsom-Skene  Urethral  Speculum 152 

131.  Simpson's  Uterine  Sound 152 

132.  Sims's  Sharp  Curette 154 

133.  Simon's  Sharp  Curette 154 

134.  Thomas's  Dull  Wire  Curette 154 

135.  Barnes's  Tent-carrier 155 

136.  Hanks's  Small  Uterine  Dilators      155 

137.  Garrigues'  Uterine  Dilator 155 

138.  Potain's  Aspirator 160 

139.  Epithelial  Cells  found  in  Urine 162 

140.  Kelly's  Urethral  Dilators      163 

141.  Kelly's  Vesical  Speculum 163 

142.  Kelly's  Suction  Apparatus 164 

143.  Pawlik's  Furrows  on  the  Anterior  Vaginal  Wall,  corresponding  to  the  trigone  166 

144.  Pawlik's  Ureteral  Catheter 166 

TREATMENT. 

145.  Budd's  Uterine  Applicator 170 

146.  Bed-pan 171 

147.  Braun's  Uterine  Syringe 173 

148.  Garrigues'  Single-current  Uterine  Tube 173 

149.  Goelet's  Double-current  Uterine  Tube     174 

150.  Keyes's  Irrigator  for  Bladder  .   .   .   .   , 175 

151.  Nott's  Double-current  Catheter 176 

152.  Thompson's  Rubber  Bag  for  Injection  into  Bladder 176 

153.  Re"caniier's  Curette 178 

154.  Garrigues'  Curved  Intra-uterine  Packing-forceps 180 

155.  Garrigues'  Straight  Intra-uterine  Packing-forceps 181 

156.  Paquelin's  Thermocautery 183 

157.  Kceberl6's  Artery-clamp 184 

158.  Onterbridge's  Permanent  Dilator  of  Cervix 185 

159.  Carrier  for  the  Same 185 

160.  Abdominal  Glass  Drainage-tube 185 

161.  Reese's  Artificial  Leech 186 

162.  Buttle's  Uterine  Scarificator    . 186 

163.  Bath-Speculum     •••.-. 187 

164.  Trocar  with  Blunt  Stylet 189 

165.  Abdominal  Belt .   .   .   . 190 

166.  Fitch's  Abdominal  Supporter 191 

167.  Inflatable  Surgical  Rubber  Cushions 194 

168.  Clover's  Crutch 197 

169.  Robb's  Leg-holder .    .   '. 198 

170.  Nozzle  with  Stopcock 199 

171.  Leavens's  Suture-tubes  .       200 

172.  Schimmelbusch's  Ligature-box 201 


ILLUSTRATIONS.  725 

FIG.  PAGE 

173.  Greig  Smith's  Ligature-box  (modified) 202 

174.  Dowd's  Condenser 203 

175.  Allis's  Ether  Inhaler 207 

176.  Esrnarch's  Chloroform  Mask 209 

177.  Garrigues'  Weight  Speculum 211 

178.  Schroeder's  Vaginal  Ketractors 212 

179.  Emmet's  Tenaculum 212 

180.  Volsella 212 

181.  Pean's  Traction-forceps 212 

182.  Tissue-forceps 213 

183.  Sims's  Sponge-holder      213 

184.  Needles 214 

185.  Needles  with  Handles 215 

186.  Sims's  Needle-holder 216 

187.  Hagedorn's  Needle-holder 216 

188.  Crosby's  Needle-holder 216 

189.  Cleveland's  Ligature-carrier 217 

190.  Bringing  Pared  Surfaces  together  with  Sutures 218 

191.  Emmet's  Counter-pressure  Hook 219 

192.  Emmet's  Wire-twister 219 

193.  Shouldering  Wire  Sutures 220 

194.  Sims's  Suture-shield 220 

195.  Beginning  a  Catgut  Tier-suture 221 

196.  Second  Deep  Row  of  Tier-suture 222 

197.  Apostoli's  Bipolar  Vaginal  and  Uterine  Exciters 229 

198.  Garrigues'  Intra-uterine  Electrode 231 

VULVA. 

199.  Hypospadias 256 

200.  Epispadias     257 

201.  Follicular  Vulvitis 267 

202.  Epithelioma  of  Vulva 284 

203.  Lupus  of  Vulva 286 

PERINEUM. 

204.  Vidal-Garrigues'  Serrefines 303 

205.  Recent  Tear  of  the  Vaginal  Entrance -306 

206.  Tait's  Flap-splitting  Operation  for  Incomplete  Laceration  of  Perineum  .   .   308 

207.  Tait's  Flap-splitting  Operation  for  Complete  Laceration  of  Perineum  .    .    .   309 

208.  Diagrams  Illustrating  Incisions  and  mode  of  Suturing  in  Tait's  Operation  .   310 

209.  Hegar-Garrigues'  Colpoperineorrhaphy  for  Incomplete  Laceration     .    .       .   313 

210.  Hegar's  Colpoperineorrhaphy  for  Complete  Laceration .   314 

211.  Submucous  Sutures 

212.  Emmet's  Operation  for  Incomplete  Laceration  (Rectocele)    - 

213.  Emmet's  Suture  for  Lifting  Pelvic  Floor •   318 

214.  Outerbridge's  Suture 

215.  Cleveland's  Suture 

216.  Diagrams  showing  Retraction  of  Fibres  after  Rupture  of  Sphincter  Ani  Muscle  320 


726  ILL  USTRA  TJONS. 

FIG.  PAGE 

217.  Sutures  for  Kepair  of  Torn  Sphincter  Ani 321 

218.  Diagram  of  Emmet's  Operation  for  Complete  Laceration  of  the  Perineum  .  321 

VAGINA. 

219.  Vaginal  Glass  Plug 331 

220.  Sims's  Operation  for  Cystocele 337 

221.  Stolz's  Operation  for  Cystocele 338 

222.  Bozeman's  Operating-Table 367 

223.  Bozeman's  Speculum 368 

224.  Bozeman's  Button 368 

225.  Walcher's  Fistula- Operation 370 

226.  Bandl's  Operation  for  Ureterovaginal  Fistula    .    .    374 

227.  Pawlik's  Operation  for  Incontinence 379 

228.  I.  E.  Taylor's  Operation  for  Rectolabial  Fistula 383 

UTERUS. 

229.  Uterus  Didelphys 388 

230.  Uterus  Unicornis 389 

231.  Uterus  Bicornis 390 

232.  Trachelorrhaphy 400 

233.  Dissecting  Metritis     ...        406 

234.  Hegar's  Amputation  of  the  Vaginal  Portion 418 

235.  Simon's  Coue-mantle-shaped  Excision  of  the  Vaginal  Portion 419 

236.  Schroeder's  Single-flap  Excision  of  the  Vaginal  Portion 419 

237.  Kuchenmeister's  Scissors 422 

238.  Simpson's  Metrotome 423 

239.  Hegar's  Funnel-shaped  Excision  of  the  Supravaginal  Cervix 428 

240.  Schroeder's  Supravagiual  Amputation  of  Cervix 429 

241.  Kaltenbach's  Supravaginal  Amputation  of  Cervix 430 

242.  Anteversiou  of  the  Uterus 434 

243.  Graily  Hewitt's  Cradle  Pessary 435 

244.  Thomas's  Auteversion  Pessary 435 

245.  Thomas's  Horseshoe-shaped  Anteversion  Pessary 436 

246.  Gehrung's  Anteversion-  Pessary 436 

247.  Anteflexion 438 

248.  Intra-uterine  Stem-Pessary 441 

249.  Eetroflexion  of  the  Uterus 443 

250.  Hodge-Emmet  Pessary 446 

251.  Fowler's  Pessary 447 

252.  Procidentia  Uteri 455 

253.  Uterine  and  Abdominal  Supporter 456 

254.  Lefort's  Prolapse-Operation     457 

255.  256.    Fritsch's  Vaginal  Hysterectomy  for  Prolapsus  of  Uterus 459,  460 

257.  Section  of  Extreme  Inversion  of  Uterus 461 

258.  Transition  from  Imbedded  to  Pedunculated  Uterine  Fibroid 470 

259.  Pedunculated  Submucous  Fibroid  Tumor  enclosed  in  Uterus 470 

260.  Pedunculated  Subperitoneal  Uterine  Fibroid 471 

261.  Intramural  Uterine  Fibroid 471 

262.  Large  Cactus-shaped  Uterus  full  of  Fibroids 472 


ILLUSTRATIONS.  727 

FIG-  PAGE 

263.  Tape-carrier      478 

264.  Thomas's  Spoon-saw 478 

265.  Bozeman's  Double-curved  Scissors 479 

266.  Segond's  Speculum 484 

267.  Long  Pressure-forceps 485 

268.  Petzer's  Self-retaining  Soft-rubber  Catheter 486 

269.  Schroeder's  Hysterectomy  Needle 487 

270.  Folk's  Needle 487 

271.  Morcellation  of  Fibroid  Tumors 489 

272.  Subcuticular  Suture 493 

273.  Closing  Peritoneal  Flap  left  on  Intestine 495 

274.  Garrigues'  Transfusion  and  Infusion  Apparatus    .    .       502 

275.  Cervical  Carcinoma  extending  into  Body  of  Uterus ,    .  507 

276.  Supravaginal  Amputation  of  Cervix  with  the  Galvanocaustic  Knife     .    .    .  517 

277.  Bernays'  Uterotractor 517 

TUBES. 

278.  Hypertrophy  of  Fallopian  Tube  due  to  Interstitial  Salpingitis 527 

279.  Tube  with  Alternating  Wide  and  Narrow  Places  due  to  Salpingitis   ....  527 

280.  Pyosalpinx  on  One  Side,  Catarrhal  and  Interstitial  Salpingitis  on  the  Other  528 

281.  Staffordshire  Knot 536 

282.  Hydrosalpinx    .    .       545 

OVAKIES. 

283.  Hematoma  of  Ovary 555 

284.  Chronic  Oophoritis,  the  enlarged  Ovary  filled  with  Minute  Cysts 560 

285.  Ovary  with  Cystic  Corpus  Luteum 560 

286.  Ovary  containing  a  Gyroma 564 

287.  Gyroma  Magnified 565 

288.  Endothelioma  (Jones) .566 

289.  Ovary  with  many  Dropsical  Follicles .  568 

290.  Bilateral  Oligocystic  Ovarian  Tumor .  568 

291.  Eokitanski's  Tumor ' 

292.  Ovaries  with  Pedunculated  Cysts -  570 

293.  Epithelial  Pouches  on  the  inside  of  a  Glandular  Ovarian  Cystoma    ....  571 

294.  Melting  of  Epithelial  Cells  by  which  the  nucleus  is  set  free  and  fluid  formed  572 

295.  Small  Glandular  Ovarian  Cystoma,  with  beginning  absorption  of  partition 

between  two  cysts 

296.  Large  Glandular  Ovarian  Cystoma,  with  numerous  secondary  cysts  and 

remnants  of  absorbed  partitions 

297.  Enormous  Glandular  Cystoma 

298.  Congenital  Ovarian  Cystoma 

299.  Excrescence  on  outer  surface  of  Glandular  Cystoma    . 
300-313.     Form-elements  in  Ovarian  Cyst-fluid 

300.  Red  Blood-corpuscles 

301.  Epithelial  Cells 

302.  Bennett's  Large  Corpuscles,  or  Nunn's  Gorged  Corpuscles     . 

303.  Colloid  Corpuscles '. 

304.  Horn  Cells             r>~8 


728  ILL  USTRA  TIONS. 

FIG.  PAGE 

305.  Proliferating  Cells 578 

306.  Ameboid  Bodies 578 

307.  Large  Bennett  Corpuscles  with  Ameboid  Movement 578 

308.  Bennett's  Small  Corpuscles,  or  Drysdale's  Corpuscles 578 

309.  Cells  with  Nucleus  and  Fine  Dark  Granules 578 

310.  Flake  of  Epithelium,  the  cells  melting  and  setting  the  nucleus  free  ....  578 

311.  Fat-granules 579 

312.  Spindle-cells  from  Myxofibromatous  Ovarian  Cyst 579 

313.  Cholesterin 579 

314.  Papillary  Ovarian  Cyst 579 

315.  Superficial  Papillomas  on  both  Ovaries 580 

316.  Dermoid  Ovarian  Cyst 581 

317.  Facies  Ovariana 591 

318.  Percussion  in  Ascites  and  Ovarian  Cyst .  599 

319.  Warren's  Ovariotomy  Trocar ' 605 

320.  Emmet's  Ovariotomy  Trocar 612 

321.  N61aton's  Cyst-forceps 612 

322.  Spencer  Wells's  Pedicle-forceps 613 

323.  Smith's  Cautery-clamp • 613 

324.  Puncturing  Pelvic  Dilator 624 

325.  Blunt  Expanding  Pelvic  Dilator ' 624 

326.  Wallich's  Chain-ligature 625 

327.  Marcy's  Method  of  Ligating  Pedicle 626 

328.  Carcinoma  of  Ovary 640 

329.  Patient  with  Carcinoma  of  Ovary     640 

PELVIS. 

330.  Diagram  of  the  Structures  in  and  adjacent  to  the  Broad  Ligament   ....  646 

331.  Frost's  Vaginal  Syringe 673 

332.  Abbe's  Intestinal  Anastomosis 689 

333.  Maunsell's  Intestinal  Invagination 689 

334.  Murphy's  Button 690 

335.  Eunning  Suture  placed  in  End  of  Bowel 691 


I 


PUBLISHED   BY 


<M 

1   W. 


0 


2  r  Walnut 


MR.  SAUNDERS,  in  presenting  to  the  profession  the  fol- 
lowing list  of  publications,  begs  to  state  that  the  aim 
has  been  to  make  them  worthy  of  the  confidence  of 
medical  book-buyers  by  the  high  standard  of  authorship 
and  by  the  excellence  of  typography,  paper,  printing, 
and  binding. 

The  works  indicated  in  the  Index  (see  next  page)  with 
an  asterisk  (*)  are  sold  by  subscription  (not  by  booksellers), 
usually  through  travelling  solicitors,  but  they  can  be  ob- 
tained direct  from  the  office  of  publication  (charges  of  ship- 
ment prepaid)  by  remitting  the  quoted  prices.  Full  descrip- 
tive circulars  of  such  works  will  be  sent  to  any  address  upon 
application. 

All  the  other  books  advertised  in  this  catalogue  arc 
commonly  for  sale  by  booksellers  in  all  parts  of  the  United 
States;  but  any  book  will  be  sent  by  the  publisher  to  any 
address  (post-paid)  on  receipt  of  the  price  herein  given. 


CONTENTS. 


Anatomy.  PAGE 

Haynes,  Manual  of  Anatomy 24 

Nancrede,  Anatomy  and  Manual  of  Dissection  .    16 
Nancrede,  Essentials  of  Anatomy 26 

Bacteriology. 

Ball,  Essentials  of  Bacteriology 26 

•Crookshank,  A  Text-Book  of  Bacteriology    ...  13 

Frothingliam,  Laboratory  Guide 20 

.McFarland,  Text-Book  of  Pathogenic  Bacteria  .  15 

Botany. 

Bastin,  Laboratory  Exercises  in  Botany 20 

Chemistry  and  Physics. 

Brockway,  Essentials  of  Physics 26 

Wolff,  Essentials  of  Chemistry 26 

Children. 

*An  American  Text- Book  of  Diseases  of  Children    8 

Griffith,  Care  of  the  Baby 21 

Powell.  Essentials  of  Diseases  of  Children  ...  26 

Clinical  Charts,  Diet,  and  Diet  Lists. 

Hart,  Diet  in  Sickness  and  in  Health 22 

Keen,  Operation  Blank 19 

Lain6,  Temperature  Chart 16 

Meigs,  Feeding  in  Early  Infancy 14 

Starr,  Diets  for  Infants  and  Children 22 

Thomas,  Detachable  Diet  Lists,  etc 22 

Diagnosis. 

Cohen  and  Eshner.  Essentials  of  Diagnosis  ...  26 
MacDonald,  Surgical  Diagnosis  and  Treatment .  29 
Vierordt  and  Stuart.  Medical  Diagnosis  ....  10 
Corwin,  Essentials  of  the  Physical  Diagnosis  of 

the  Thorax 18 

Dictionaries, 

Keating  and  Hamilton,  New  Pronouncing  Dic- 
tionary of  Medicine 10 

Morten,  Nurses'  Dictionary  of  Medical  Terms  .   22 
Saunders'  Pocket  Medical  Lexicon 17 

Ear. 

Gleason,  Essentials  of  Diseases  of  the  Ear   ...  26 

Electricity. 

Stewart  and  Lawrance,  Essentials  of  Medical 
Electricity '26 

Embryology. 

Heisler,  Text-Book  of  Embryology 29 

Eye,  Nose,  and  Throat. 

De  Schweinitz,  Diseases  of  the  Eye  ......    14 

Jackson  and  Gleason,  Essentials  of  Diseases  of 

Eye,  Nose,  and  Throat 26 

Kyle,  Manual  of  Diseases  of  Nose  and  Throat .  .   24 

Genito-uriiiary. 

Hyde,  Syphilis  and  the  Venereal  Diseases   ...    24 
Martin,  Essentials  of  Minor  Surgery,  Bandaging, 

and  Venereal  Diseases 26 

Saundby,  Renal  and  Urinary  Diseases 27 

Gynecology. 

*An  American  Text-Book  of  Gynecology   ....  9 

Cragin,  Essentials  of  Gynecology 26 

Garrigues,  Diseases  of  Women Ib 

Long,  Syllabus  ol  Gynecology 19 

Histology. 

Clarkson,  Text-Book  of  Histology 15 

Life  Insurance. 

Keating,  How  to  Examine  for  Life  Insurance  .  .   21 
Materia  Medica  and  Therapeutics. 

*An  American  Text  Book  of  Applied  Therapeu- 
tics    4 

Butler,  Text-Book  of  Materia  Medica,  Therapeu- 
tics, and  Pharmacology 27 

Cerna,  Notes  on  the  Newer  Remedies 17 

Griffin,  Manual  of  Materia  Medica  and  Therapeu- 
tics  24 

Morris.  Essentials  of  Materia  Medica,  etc.    ...    26 

2 


PAGE 

Saunders'  Pocket  Medical  Formulary 17 

Stevens,  Manual  of  Therapeutics 17 

Thornton,  Dose-Book  and  Prescription- Writing .  24 

Warren,  Surgical  Pathology  and  Therapeutics  .  11 

Medical  Jurisprudence. 

Chapman,    Medical   Jurisprudence   and   Toxi- 
cology     24 

Semple,  Essentials  of  Legal  Medicine,  etc.    ...    26 

Medicine. 

*An  American  Text-Book  of  Practice 7 

*Gould  and  Pyle,  Anomalies  and  Curiosities  of 

Medicine 28 

Lockwood,  Manual  of  the  Practice  of  Medicine  24 

Morris,  Essentials  of  the  Practice  of  Medicine  .  26 
Saunders'  American  Year-Book  of  Medicine  and 

Surgery 30 

Stevens,  Manual  of  the  Practice  of  Medicine  .  .  16 

Nervous  Diseases  and  Insanity. 

Burr,  Manual  of  Nervous  Diseases 24 

Shaw.Essentials  of  Nervous  Diseases  and  Insanity  26 

Nursing. 

Griffith,  Care  of  the  Baby 21 

Hampton,  Nursing:  its  Principles  and  Practice  21 

Stoney,  Practical  Points  in  Private  Nursing  ...  13 

Obstetrics. 

*An  American  Text-Book  of  Obstetrics 5 

Ashton,  Essentials  of  Obstetrics 26 

Boisliniere,  Obstetric  Accidents 20 

Dorland,  Manual  of  Obstetrics 24 

Norris,  Syllabus  of  Obstetrical  Lectures 19 

Pathology. 

Semple,   Essentials  of  Pathology  and  Morbid 

Anatomy 26 

Senn,  Pathology   and  Surgical  Treatment  of 

Tumors ; 11 

Stengel,  Manual  of  Pathology 24 

Warren,  Surgical  Pathology  and  Therapeutics  .    11 

Pharmacy. 

Sayre,  Essentials  of  Pharmacy 26 

Physiology. 

*An  American  Text-Book  of  Physiology   ....  3 

Hare,  Essentials  of  Physiology 26 

Raymond,  Manual  of  Physiology 24 

Stewart,  A  Manual  of  Physiology 15 


Skiagraphy. 

Rowland,  Archives  of  Clinical  Skiagraphy  ... 

Skin. 

*Pictorial  Atlas  of  Skin  Diseases    ........ 

Stelwagon,  Essentials  of  Diseases  of  the  Skin  .  . 

Surgery. 

*An  American  Text-Book  of  Surgery  ...... 

Beck,  Surgical  Asepsis  .............. 

DaCosta,  Manual  of  Surgery  ........... 

Keen,  Operation  Blank    ............. 

MacDonald,  Surgical  Diagnosis  and  Treatment  . 
Martin,  Essentials  of  Surgery    .......... 

Martin,  Essentials  of  Minor  Surgery,  etc  ..... 

Pye,  Elementary  Bandaging  and  Surgical  Dress- 

ing ..................... 

Saunders'  American  Year-Book  of  Medicine  and 

Surgery    ................... 

Senn,  Pathology  and  Surgical  Treatment  of 

Tumors     ................... 

Senn,  Syllabus  of  Surgery  ............ 

Warren,  Surgical  Pathology  and  Therapeutics  . 

Urine. 

Wolff,  Essentials  of  Examination  of  Urine 


12 


26 


Miscellaneous. 

Gross,  Autobiography  of  ............    12 

Saunders'  New  Aid  Series  of  Manuals  ....   23,  24 

Saunders'  Question  Compends  ........    25,  26 

Thresh,  Water  and  Water  Supplies    .......    15 


CATALOGUE  OF  MEDICAL    WORKS. 

For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
WILLIAM  H.  HOWELL,  PH.  D.,  M.  D.,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume  of  1052 
pages,  fully  illustrated.  Prices:  Cloth,  $6.00  net;  Sheep  or  Half-Morocco, 
$7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  in  one 
volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers  who  have 
given  especial  study  to  that  part  of  the  subject  upon  which  they  write.  The 
completed  work  represents  the  present  status  of  the  science  of  Physiology,  par- 
ticularly from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

American  teachers  of  physiology  have  not  been  altogether  satisfied  with  the 
text-books  at  their  disposal.  The  defects  of  most  of  the  older  books  are  that  they 
have  not  kept  pace  with  the  rapid  changes  in  modern  physiology,  while  few  if  any 
of  the  newer  books  have  been  uniformly  satisfactory  in  their  treatment  of  all  parts 
of  this  many-sided  science.  Indeed,  the  literature  of  experimental  physiology  is 
so  great  that  it  would  seem  to  be  almost  impossible  for  any  one  teacher  to  keep 
thoroughly  informed  on  all  topics. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account  upon 
a  comprehensive  knowledge  of  the  subject  assigned  to  him  ;  another,  and  perhaps 
the  most  important,  advantage,  is  that  the  student  gains  the  point  of  view  of  a 
number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be  obtained 
by  following  courses  of  instruction  under  different  teachers.  The  different  stand- 
points assumed,  and  the  differences  in  emphasis  laid  upon  the  various  lines  of  pro- 
cedure, chemical,  physical,  and  anatomical,  should  give  the  student  a  better  insight 
into  the  methods  of  the  science  as  it  exists  to-day.  The  work  will  also  be  found 
useful  to  many  medical  practitioners  who  may  wish  to  keep  in  touch  with  the 
development  of  modern  physiology. 

The  main  divisions  of  the  subject-matter  are  as  follows  :  General  Physiology  of 
Muscle  and  Nerve — Secretion — Chemistry  of  Digestion  and  Nutrition — Movements 
of  the  Alimentary  Canal,  Bladder,  and  Ureter — Blood  and  Lymph — Circulation — 
Respiration — Animal  Heat — Central  Nervous  System — Special  Senses — Special 
Muscular  Mechanisms — Reproduction — Chemistry  of  the  Animal  Body. 

CONTRIBUTORS: 


HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medical  School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  University,  N.  Y. 
(College  of  Physicians  and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.D., 

Head-Professor  of  Neurology,  University  of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins  University. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Prof,  of  Physiology,  Columbia  University, 
N.  Y.  (College  of  Physicians  and  Surgeons). 


WARREN  P.  LOMBARD,  M.  D., 

Professor  of  Physiology,  University  of  Michigan. 

GRAHAM  LUSK,  Ph.D., 

Professor  of  Physiology,  Yale  Medical  School. 

W.  T.  PORTER,  M.  D., 

Assistant  Professor  of  Physiology,  Harvard  Medical 
School. 

EDWARD  T.  REICHERT,  M.  D., 

Professor  of  Physiology,  University  of  Pennsylvania. 

HENRY  SEWALL,  Ph.D.,  M.  D., 

Professor  of  Physiology,  Medical  Department,  Uni- 
versity of  Denver. 


W.  B.  SAUNDERS'  ILLUSTRATED 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
JAMES  C.  WILSON,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  $7.00  net;  Sheep  or 
Half-Morocco,  $8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon  mod- 
ern pathologic  doctrines,  beginning  with  the  intoxications  and  following  with 
infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined  origin,  and 
finally  the  disorders  of  the  several  bodily  systems — digestive,  respiratory,  circu- 
latory, renal,  nervous,  and  cutaneous.  It  was  thought  proper  to  include  also  a 
consideration  of  the  disorders  of  pregnancy. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of  the 
specialties. 

CONTRIBUTORS: 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  111. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Phila.,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.  Edes,  Jamaica  Plain,  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Col. 
F.  Forchheimer,  Cincinnati,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Paris,  France. 


Dr.  James  Hendrie  Lloyd,  Phila.,  Pa. 
John  Noland  Mackenzie,  Bait.,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup,  New  York  City. 
\Villiam  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Phila.,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare,  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Phila.,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  alleviation 
of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of  the 
book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be  pursued 
at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used  at  one 
time  or  another. 

While  the  scientific  superiority  and  the  practical  desirability  of  the  metric 
system  of  weights  and  measures  is  admitted,  it  has  not  been  deemed  best  to 
discard  entirely  the  older  system  of  figures,  so  that  both  sets  have  been  given 
where  occasion  demanded. 


CATALOGUE  OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by  RICH- 
ARD C.  NORRIS,  M.  D.;  Art  Editor,  ROBERT  L.  DICKINSON,  M.  D.  One 
handsome  octavo  volume  of  over  1000  pages,  with  nearly  900  colored  and 
half-tone  illustrations.  Prices  :  Cloth,  $7.00  ;  Sheep  or  Half-Morocco,  $8.00. 

The  advent  of  each  successive  volume  of  the  series  of  the  AMERICAN  TEXT- 
BOOKS has  been  signalized  by  the  most  flattering  comment  from  both  the  Press  and 
the  Profession.  The  high  consideration  received  by  these  text-books,  and  their 
attainment  to  an  authoritative  position  in  current  medical  literature,  have  been 
matters  of  deep  international  interest,  which  finds  its  fullest  expression  in  the 
demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparation  of  the  "AMERICAN  TEXT-BOOK  OF  OBSTETRICS  "  the  editor 
has  called  to  his  aid  proficient  collaborators  whose  professional  prominence  entitles 
them  to  recognition,  and  whose  disquisitions  exemplify  Practical  Obstetrics. 
While  these  writers  were  each  assigned  special  themes  for  discussion,  the  correla- 
tion of  the  subject-matter  is,  nevertheless,  such  as  ensures  logical  connection  in 
treatment,  the  deductions  of  which  thoroughly  represent  the  latest  advances  in  the 
science,  and  which  elucidate  the  best  modern  methods  of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative  matter. 
The  production  of  the  illustrations'  had  been  in  progress  for  several  years,  under 
the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose  artistic  judg- 
ment and  professional  experience  is  due  the  most  sumptuously  illustrated 
•work  of  the  period.  By  means  of  the  photographic  art,  combined  with  the 
skill  of  the  artist  and  draughtsman,  conventional  illustration  is  superseded  by 
rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CONTRIBUTORS: 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Barton  Cooke  Hirst. 
Henry  J.  Garrigu.es. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"  At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects,  viz. ; 
Fir?t.  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  department  who  have 
taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the  illustrations,  and  last,  but 
not  least,  the  conciseness  and  clearness  with  which  the  text  is  rendered.  This  is  an  entirely  new 
composition,  embodying  the  highest  knowledge  of  the  art  as  it  stands  to-day  by  authors  who  occupy 
the  front  rank  in  their  specialty,  and  there  are  many  of  them.  We  cannot  turn  over  these  pages 
without  being  struck  by  the  superb  illustrations  which  adorn  so  many  of  them.  We  are  confident 
that  this  most  practical  work  will  find  instant  appreciation  by  practitioners  as  well  as  students. "- 
New  York  Medical  Times. 


Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent  medical 
work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work,  which  alone  is 
sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours, 

ALEX.  J.  C.  SKENE. 


W.  B.  SAUNDERS1  ILLUSTRATED 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  WIL- 
LIAM W.  KEEN,  M.  D.,  LL.D.,  and  J.  WILLIAM  WHITE,  M.  D.,  PH.  D. 
Forming  one  handsome  royal-octavo  volume  of  1250  pages  (10x7  inches), 
with  500  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.  Prices  :  Cloth,  $7.00  ;  Sheep  or  Half- Morocco,  $8.00  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED, 
With  a  Section  devoted  to  "The  Use  of  the  Rbntgen  Rays  in  Surgery." 

The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
same  time  be  recommended  to  the  medical  student  has  been  deeply  felt,  especially 
by  teachers  of  surgery ;  hence,  when  it  was  sug- 
gested to  a  number  of  these  that  it  would  be 
well  to  unite  in  preparing  a  text-book  of  this 
description,  great  unanimity  of  opinion  was 
found  to  exist,  and  the  gentlemen  below  named 
gladly  consented  to  join  in  its  production. 

Especial  prominence  has  been  given  to  Surg- 
ical Bacteriology,  a  feature  which  is  believed  to 
be  unique  in  a  surgical  text-book  in  the  English 
language.  Asepsis  and  Antisepsis  have  received 
particular  attention.  The  text  is  brought  well 
up  to  date  in  such  important  branches  as  cere- 
bral, spinal,  intestinal,  and  pelvic  surgery,  the 
most  important  and  newest  operations  in  these 
departments  being  described  and  illustrated. 

The  text  of  the  entire  book  has  been  sub- 
mitted to  all  the  authors  for  their  mutual  criti- 
cism and  revision — an  idea  in  book-making 
that  is  entirely  new  and  original.  The  book  as 
a  whole,  therefore,  expresses  on  all  the  im- 
portant surgical  topics  of  the  day  the  consensus 
of  opinion  of  the  eminent  surgeons  who  have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very  many 
of  them  are  original  and  faithful  reproductions  of  photographs  taken  directly  from 
patients  or  from  specimens,  and  the  modern  improvements  in  the  art  of  engraving 
have  enabled  the  publisher  to  produce  illustrations  which  it  is  believed  are  superior 
to  those  in  any  similar  work. 

CONTRIBUTORS: 


Specimen  Illustration  (largely  reduced). 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  N.  Y. 
Lewis  S.  Pilcher,  Brooklyn,  N.  Y. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thomson,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"  If  this  text-book  is  a  fair  reHex  of  the  present  position  of  American  surgery,  we  must  admit 
it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very  carefully  to 
their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — London  Lancet. 


"  The  soundness  of  the  teachings  contained  in  this  work  needs  no  stronger  guarantee  than  is 
afforded  by  the  names  of  its  authors." — Meiical  News,  Philadelphia. 


CATALOGUE   OF  MEDICAL    WORKS. 

For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  WILLIAM  PEPPER,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  about 
1000  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume:  Cloth,  $5.00  net ;  Sheep  or  Half- Morocco,  §6.00  net. 

VOLUME   I.  CONTAINS: 

Hygiene. — Fevers  (Ephemeral,  Simple  Con-  \  Hydrophobia,  Trichinosis,  Actinomycosis,  Glan- 
tinued,  Typhus,  Typhoid,  Epidemic  Cerebro-  ders,  and  Tetanus. — Tuberculosis,  Scrofula, 
•  :>inal  Meningitis,  and  Relapsing). — Scarlatina,  •  Syphilis,  Diphtheria,  Erysipelas,  Malaria,  Choi- 
Measles,  Rotheln,  Variola,  Varioloid,  Vaccinia,  j  era,  and  Yellow  Fever. — Nervous,  Muscular,  and 
Varicella,  Mumps,  \Vhooping-cough,  Anthrax,  i  Mental  Diseases. 

VOLUME    II.  CONTAINS; 

Urine  (Chemistry  and  Microscopy). — Kidney  Liver,  and  Pancreas. —  Diathetic  Diseases  (Rheu- 

ittd  Lungs. — Air-passages  (Larynx  and  Bronchi)  .  matism,  Rheumatoid  Arthritis,  Gout,  Lithaemia 

and    Pleura.  —  Pharynx,    CEsophagus,    Stomach  and  Diabetes). —  Blood  and  Spleen. — Infiamma 

and    Intestines  (including  Intestinal   Parasites),  tion,  Embolism,  Thrombosis,  Fever,  and  Bacte 

Heart,  Aorta,  Arteries  and  Veins. — Peritoneum,  riology. 

The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but  are 
exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causation, 
Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large  number 
of  approved  formulae.  The  recent  advances  made  in  the  study  of  the  bacterial 
origin  of  various  diseases  are  fully  described,  as  well  as  the  bearing  of  the  know- 
ledge so  gained  upon  prevention  and  cure.  The  subjects  of  Bacteriology  as  a 
whole  and  of  Immunity  are  fully  considered  in  a  separate  section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without  con 
suiting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS: 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore.' 


Dr.  William  Pepper,  Philadelphia. 

W.  Oilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker.  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best  text- 
!x>oks  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second  and  last 
volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our  opinion,  the 
BEST  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough,  accurate,  and  clear. 
It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well  bound.  It  is  a  model  of 
what  the  modern  text-book  should  be." — New  York  Medical  Journal. 

"  A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of  sound 
knowledge." — American  Lancet. 

."  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  wh:ch  he  may  implicitly  rely." — 
Edinburgh  Medical  Journal. 


W.  B.  SAUNDERS  ILLUSTRATED 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  STARR,  M.  D.f 
assisted  by  THOMPSON  S.  WESTCOTT,  M.  D.  In  one  handsome  royal-8vo  vol 
umeof  1190  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and  colored 
plates.  Prices:  Cloth,  $7.00  net;  Sheep  or  Half-Morocco,  $8.00  net. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  podiatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to  be 
a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practitioner 
and  the  advanced  student. 

One  decided  innovation  is  the  large  number  of  authors,  nearly  every  article 
being  contributed  by  a  specialist  in  the  line  on  which  he  writes.  This,  while 
entailing  considerable  labor  upon  the  editors,  has  resulted  in  the  publication  of  a 

WOrk  THOROUGHLY  NEW  AND  ABREAST  OF  THE  TIMES. 

Especial  attention  has  been  given  to  the  consideration  of  the  latest  accepted 
teaching  upon  the  etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the 
disorders  of  children,  with  the  introduction  of  many  special  formulas  and  thera- 
peutic procedures. 

Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear,  Nose 
and  Throat,  and  the  Skin  ;  while  the  introductory  chapters  cover  fully  the  important 
subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of  Food.  Trache- 
otomy, Intubation,  Circumcision,  and  such  minor  surgical  procedures  coming 
within  the  province  of  the  medical  practitioner,  are  carefully  considered. 

CONTRIBUTORS: 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia. 
J.  M.  DaCosta,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
London  Carter  Gray,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway,  St.  Louis. 
M.  P.  Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik,  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  M.  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K.  Mills,  Philadelphia. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  A.  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  M.  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia. 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
M.  Allen  Starr,  New  York. 
J.  Madison  Taylor,  Philadelphia. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
Thompson  S.  Westcott,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 


J.  William  White,  Philadelphia. 


C.  Wilson,  Philadelphia. 


CATALOGUE  OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  BALDY,  M.  D.  Forming  a  handsome  royal-octavo  volume, 
with  360  illustrations  in  text  and  37  colored  and  half-tone  plates.  Prices: 
Cloth,  $6.00  net;  Sheep  or  Half- Morocco,  $7.00  net. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the   text,   have  been   omitted,   the   illustrations  being  largely 

_  depended  upon  to  eluci- 
jj?//'date  the  anatomy  of  the 
parts.  This  work,  which 
is  thoroughly  practical  in 
its  teachings,  is  intended, 
as  its  title  implies,  to  be 
a  working  text-book  for 
physicians  and  students. 
A  clear  line  of  treatment 
has  been  laid  down  in 
every  case,  and  although 
no  attempt  has  been  made 
to  discuss  mooted  points, 
still  the  most  important 
of  these  have  been  noted 
arid  explained.  The  ope- 
rations recommended  are 
fully  illustrated,  so  that 
the  reader,  having  a  pic- 
ture of  the  procedure  de- 
scribed in  the  text  under 
fail  to 
All  ex- 
traneous matter  and  dis- 
cussions have  been  care- 
fully excluded,  the  attempt 
being  made  to  allow  no 
unnecessary  details  to  cumber  the  text.  The  subject-matter  is  brought  up  to  date 
at  every  point,  and  the  work  is  as  nearly  as  possible  the  combined  opinions  of  the 
ten  specialists  who  figure  as  the  authors. 

The  work  is  well  illustrated  throughout  with  wood-cuts,  half-tone  and  colored 
plates,  mostly  selected  from  the  authors'  private  collections. 


his   eye,    cannot 
grasp  the  idea. 


Specimen  Illustration. 


CONTRIBUTORS: 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
J.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor.' 
George  M.  Tuttle. 


"  The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most  com- 
plete exponent  of  gynecology  which  we  have.     No  subject  seems  to  have  been  neglected and 

the  gynecologist  and  surgeon  and  the  general  practitioner,  who  has  any  desire  to  practise  diseases 
of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations  and  plates  the  book  sur 
passes  anything  we  have  seen." — Boston  Medical  and  Surgical  Journal. 


io  W.  B.  SAUNDERS'  ILLUSTRATED 

A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  JOHN 
M.  KEATING,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia ;  Vice- President  of  the  American  Paediatric  Society ;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclopaedia 
of  the  Diseases  of  Children,"  etc.  ;  and  HENRY  HAMILTON,  Author  of  a  "A 
New  Translation  of  Virgil's  ^Eneid  into  English  Rhyme;"  Co-Author  of 
"Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collaboration  of  J.  CHALMERS 
DACOSTA,  M.  D.,  and  FREDERICK  A.  PACKARD,  M.  D.  With  an  Appendix, 
containing  Important  Tables  of  Bacilli,  Micrococci,  Leucomai'nes,  Ptomaines ; 
Drugs  and  Materials  used  in  Antiseptic  Surgery  ;  Poisons  and  their  Antidotes ; 
Weights  and  Measures ;  Thermometric  Scales ;  New  Official  and  Unofficial 
Drugs,  etc.  One  volume  of  over  800  pages.  Second  Revised  Edition. 
Prices:  Cloth,  $5.00;  Sheep  or  Half-Morocco,  §6.00  net ;  Half- Russia,  $6.50 
net,  with  Denison's  Patent  Ready- Reference  Index  ;  without  Patent  Index, 
Cloth,  $4.00  net;  Sheep  or  Half-Morocco,  $5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending  it 
to  my  classes." 

HENRY  M.  LYMAN,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Ruth  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in  size 
and  sufficiently  full  for  ordinary  use." 

C.  A.  LINDSLEY,  M.  D., 
Professor  of  Theory  and  Practice  of  Medicine,  Medical  Depl.   Yale  University  ; 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn. 

MEDICAL  DIAGNOSIS.  By  Dr.  OSWALD  VIERORDT,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions,  from  the 
Second  Enlarged  German  Edition,  with  the  author's  permission,  by  FRANCIS 
H.  STUART,  A.  M.,  M.  D.  Third  and  Revised  Edition.  In  one  handsome 
royal-octavo  volume  of  700  pages,  1 78  fine  wood-cuts  in  text,  many  of  which 
are  in  colors.  Prices:  Cloth,  $4.00  net;  Sheep  or  Half-Morocco,  $5.00  net; 
Half- Russia,  $5.50  net. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clinical 
work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accuracy. 
It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over  without 
explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a  factor  in 
the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and  Italian. 
The  "issue  of  a  third  American  edition  within  two  years  indicates  the  favor  with  which 
it  has  been  received  by  the  profession. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the  volume 
before  us.  All  the  chapters  are  full,  and  leave  little  to  be  desired  by  the  reader.  Each  particular 
item  in  the  consideration  of  an  organ  or  apparatus,  which  is  necessary  to  determine  a  diagnosis  of 
any  disease  of  that  organ,  is  mentioned  ;  nothing  seems  forgotten.  The  chapters  on  diseases  of  the 
circulatory  and  digestive  apparatus  and  nervous  system  are  especially  full  and  valuable.  Not- 
withstanding a  few  minor  errors  in  translating,  which  are  of  small  importance  to  the  accuracy 
of  the  rest  of  the  volume,  the  reviewer  would  repeat  that  the  book  is  one  of  the  best — probably, 
the  best — which  has  fallen  into  his  hands.  An  excellent  and  comprehensive  index  of  nearly  one 
hundred  pages  closes  the  volume." — University  Medical  Magazine,  Philadelphia. 


CATALOGUE   OF  MEDICAL    WORKS. 


PATHOLOGY  AND    SURGICAL  TREATMENT  OF  TUMORS. 

By  N.  SENN,  M.  D.,  PH.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College  ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief,  St.  Joseph's 
Hospital,  Chicago.  710  pages,  515  engravings,  including  full-page  colored 
plates.  Prices:  Cloth,  $6.00  net ;  Half-Morocco,  $7.00  net. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  degree 
incompatible  with  its  scientific  and  clinical  importance.  The  author  spent  many 
years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains  to  present 
it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student,  a  work 
of  reference  for  the  busy  practitioner,  and  a  reliable,  safe  guide  for  the  surgeon. 
The  more  difficult  operations  are  fully  described  and  illustrated.  More  than  one 
hundred  of  the  illustrations  are  original,  while  the  remainder  were  selected  from 
books  and  medical  journals  not  readily  accessible  to  the  student  and  the  general 
practitioner. 

"  The  appearance  of  such  a  work  is  most  opportune.  ...  In  design  and  execution  the  work  is 
such  as  will  appeal  to  every  student  who  appreciates  the  logical  examination  of  facts  and  the  prac- 
tical exemplification  of  well-digested  clinical  observation." — Medical  Record,  New  York. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illustrated,  and 
will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language  for  some  years. 
The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has  given  a  notable  and 
lasting  contribution  to  surgery." — Journal  of  American  Medical  Association,  Chicago. 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  JOHN 
COLLINS  WARREN,  M.  D.,  LL.  D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University ;  Surgeon  to  the  Massachusetts  General  Hospital, 
etc.  A  handsome  octavo  volume  of  832  pages,  with  136  relief  and  litho- 
graphic illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which  were 
drawn  by  William  J.  Kaula  from  original  specimens.  Prices:  Cloth,  $6.00 
net;  Half-Morocco,  $7.00  net. 

"  The  volume  is  for  the  bedside,  the  amphitheatre,  and  the  ward.  It  deals 
with  things  not  as  we  see  them  through  the  microscope  alone,  but  as  the  practitioner 
sees  their  effect  in  his  patients  ;  not  only  as  they  appear  in  and  affect  culture- 
media,  but  also  as  they  influence  the  human  body;  and,  following  up  the  demon- 
strations of  the  nature  of  diseases,  the  author  points  out  their  logical  treatment" 
{New  York  Medical  Journal}.  "Indeed,  the  volume  maybe  termed  a  modern 
medical  classic,  for  such  is  the  position  to  which  it  has  already  risen  "  (Medical 
Age,  Detroit),  "  and  is  the  handsomest  specimen  of  bookmaking  *  -;  *  that  has 
ever  been  issued  from  the  American  medical  press"  {American  Journal  of  the 
Medical  Sciences,  Philadelphia). 

Without  Exception,  the  Illustrations  are  the  Best  ever  Seen  in  a  Work  of 

this  Kind. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  exception, 
from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work  of  this  kind. 
*  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring  and  detail  as 
almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel  of  a  microscope  at  a 
well-mounted  section." — Annals  of  Surgery,  Philadelphia. 


12  W.  B.   SAUNDERS'   ILLUSTRATED 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus 
Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
SAMUEL  W.  GROSS,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  HALLER 
GROSS,  A.  M.,  of  the  Philadelphia  Bar.  Preceded  by  a  Memoir  of  Dr.  Gross, 
by  the  late  Austin  Flint,  M.  D.,  LL.D.  In  two  handsome  volumes,  each  con- 
taining over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine  Frontis- 
piece engraved  on  steel.  Price,  $5.00  net. 

This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  before  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many  of 
the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  statesmen, 
scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in  Europe ; 
the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 

"  Dr.  Gross  .  .  .  was  perhaps  the  most  eminent  exponent  of  medical  science  that  America  has  yet 
produced.  His  Autobiography,  related  as  it  is  with  a  fulness  and  completeness  seldom  to  be  found 
in  such  works,  is  an  interesting  and  valuable  book.  He  comments  on  many  things,  especially,  of 
course,  on  MEDICAL  MEN  AND  MEDICAL  PRACTICE,  in  a  very  interesting  way.  Details  of  profes- 
sional life  have  also  much  in  them  that  will  be  new." — The  Spectator,  London,  England. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPH- 
ILITIC AFFECTIONS  (American  Edition).  Translation  from  the 
French.  Edited  by  J.  J.  PRINGLE,  M.  B.,  F.  R.  C.  P.,  Assistant  Physician 
to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the  Middle- 
sex Hospital,  London.  Photo-lithochromes  from  the  famous  models  of  der- 
matological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis  Hospital, 
Paris,  with  explanatory  wood-cuts  and  text.  In  12  Parts,  at  $3.00  per  Part. 
Parts  i  to  8  now  ready. 

"  The  plates  are  beautifully  executed." — JONATHAN  HUTCHINSON,  M.  D.  (London  Hospital). 

"I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and  will  be 
of  great  value  to  all  studying  dermatology." — STEPHEN  MACKENZIE,  M.  D.  (London  Hospital). 

"The  plates  in  this  Atlas  are  remarkably  accurate  and  artistic  reproductions  of  typical  ex- 
amples of  skin  disease.  The  work  will  be  of  great  value  to  the  practitioner  and  student." — 
WILLIAM  ANDERSON,  M.  D.  (St.  Thomas  Hospital). 

"  If  the  succeeding  parts  of  this  Atlas  are  to  be  similar  to  Part  I,  now  before  us,  we  have  no 
hesitation  in  cordially  recommending  it  to  the  favorable  notice  of  our  readers  as  one  of  the  finest 
dermatological  atlases  with  which  we  are  acquainted." — Glasgow  Medical  Journal,  Aug.,  1895. 

"Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present  one 
promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the  general  practi- 
tioner."— American  Medico- Surgical  Bulletin,  Feb.  22,  1896. 

"  The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important  feature 
which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which  nothing,  we  ven- 
ture to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general  merit." — New  York 
Medical  Journal,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture  by 
the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made.  We  pre- 
dict for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world  where  the 
names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  I,  1896. 


CATALOGUE  OF  MEDICAL    WORKS.  13 

PRACTICAL    POINTS    IN    NURSING.      For   Nurses   in   Private 

Practice.  By  EMILY  A.  M.  STONTEY,  Graduate  of  the  Training-School  for 
Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely  illustrated 
with  73  engravings  in  the  text,  and  9  colored  and  half-tone  plates.  Cloth. 
Price,  $1.75  net. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  of  private  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse :  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room  :   its  selection,  preparation,  and  management. 

III.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 

cologic cases. 

IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 

VI.   Nursing  of  the  New-born  and  Sick  Children. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  APPENDIX  contains  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick  ;  Recipes  for 
Invalid  Foods  and  Beverages  ;  Tables  of  Weights  and  Measures  ;  Table  for  Com- 
puting the  Date  of  Labor ;  List  of  Abbreviations  ;  Dose-List ;  and  a  full  and  com- 
plete Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"  There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially  endorsed 
by  a  medical  journal  as  can  this  one.'' — Therapeutic  Gazette,  Aug.  15,  1896. 

"  This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of  private 
nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to  meet  the  various 
emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily  needed  in  the  illness  of  her 
patient." — American  Journal  of  Obstetrics  and  Diseases  of  Women  and  Children,  Aug.,  1896. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the  assurance 
of  benefit."—  Ohio  Medical  Journal,  Aug.,  1896. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and 
Moulds,  Haematozoa,  and  Psorosperms.  By  EDGAR  M.  CROOK- 
SHANK,  M.  B.,  Professor  of  Comparative  Pathology  and  Bacteriology,  King's 
College,  London.  A  handsome  octavo  volume  of  700  pages,  illustrated  with 
273  engravings  in  the  text,  and  22  original  and  colored  plates.  Price, 
$6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"MANUAL  OF  BACTERIOLOGY,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised'  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Officers 
of  Health,  and  for  Veterinary  Inspectors. 


W.  B.  SAUNDERS'  ILLUSTRATED 


DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Practice. 
By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  Philadelphia,  etc.  A  handsome  royal-octavo  volume 
of  679  pages,  with  256  fine  illustrations,  many  of  which  are  original,  and  2 
chromo-lithographic  plates.  Prices:  Cloth,  $4.00  net;  Sheep  or  Half- 
Morocco,  $5.00  net. 

The  object  of  this  work  is  to  present  to  the  student,  and  to  the  practitioner  who 

is  beginning  work  in  the  fields  of  ophthal- 
mology, a  plain  description  of  the  optical 
defects  and  diseases  of  the  eye.  To  this 
end  special  attention  has  been  paid  to  the 
clinical  side  of  the  question ;  and  the 
method  of  examination,  the  symptoma- 
tology leading  to  a  diagnosis,  and  the 
treatment  of  the  various  ocular  defects 
have  been  brought  into  prominence. 

SECOND    EDITION,   REVISED   AND 
GREATLY    ENLARGED. 

The  entire  book  has  been  thoroughly 

specimen  illustration.  revised.      In  addition  to  this  general  re- 

vision, special  paragraphs  on  the  following 

new  matter  have  been  introduced  :  Filamentous  Keratitis,  Blood-staining  of  the 
Cornea,  Essential  Phthisis  Bulbi,  Foreign  Bodies  in  the  Lens,  Circinate  Retinitis, 
Symmetrical  Changes  at  the  Macula  Lutea  in  Infancy,  Hyaline  Bodies  in  the 
Papilla,  Monocular  Diplopia,  Subconjunctival  Injections  of  Germicides,  Infiltra- 
tion-Anaesthesia, and  Sterilization  of  Collyria.  Brief  mention  of  Ophthalmia 
Nodosa,  Electric  Ophthalmia,  and  Angioid  Streaks  in  the  Retina  also  finds  place. 
An  Appendix  has  been  added,  containing  a  full  description  of  the  method  of  deter- 
mining the  corneal  astigmatism  with  the  ophthalmometer  of  Javal  and  Schiotz, 
and  the  rotations  of  the  eyes  with  the  tropometer  of  Stevens.  The  chapter  on 
Operations  has  been  enlarged  and  rewritten. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students  as  a 
reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon  the  study 
of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  The  work  is  characterized  by  a  lucidity  of  expression  which  leaves  the  reader  in  no  doubt  as 
to  the  meaning  of  the  language  employed.  .  .  .  \Ve  know  of  no  work  in  which  these  diseases  are 
dealt  with  more  satisfactorily,  and  indications  for  treatment  more  clearly  given,  and  in  harmony  with 
the  practice  of  the  most  advanced  ophthalmologists." — Maritime  Medical  News. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  News. 

"  The  latest  and  one  of  the  best  books  on  Ophthalmology.  The  book  is  thoroughly  up  to  date, 
and  is  certainly  a  work  which  not  only  commends  itself  to  the  student,  but  is  a  ready  reference  for 
the  busy  practitioner." — International  Medical  Magazine. 

FEEDING  IN  EARLY  INFANCY.  By  ARTHUR  V.  MEIGS,  M.  D. 
Bound  in  limp  cloth,  flush  edges.  Price,  25  cents  net. 

SYNOPSIS:  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Earlj 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feeding — 
Intervals  between  Feedings— Increase  in  Amount  of  Food  at  Different  Periods  of 
Infant  Development — Umuitableness  of  Condensed  Milk  as  a  Substitute  for  Moth- 
er's Milk — Objections  to  Sterilization  or  "Pasteurization"  of  Milk — Advances 
made  in  the  Method  of  Artificial  Feeding  of  Infants.' 


CATALOGUE  OF  MEDICAL    WORKS.  15 


A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  ARTHUR  CLARKSOX,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
$6.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
methods  of  Histology ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  JOSEPH  MCFARLAXD, 
M.  D,,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.  359  pages,  finely  illustrated.  Cloth.  Price, 
$2.50  net. 

The  book  presents  a  concise  account  of  the  technical  procedures  necessary  in 
the  study  of  Bacteriology.  It  describes  the  life-history  of  pathogenic  bacteria,  and 
the  pathological  lesions  following  invasions. 

The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  in  this  department  of  med- 
ical science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him. 

"  The  author  has  succeeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic  bac- 
teria. .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking  students 
of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896. 

A  MANUAL  OF  PHYSIOLOGY,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  STEWART,  M.  A.,  M.  D.,  D.  Sc., 
lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  Xew 
Museums,  Cambridge  University;  Professor  of  Physiology  in  the  Western 
Reserve  University,  Cleveland,  Ohio.  Handsome  octavo  volume  of  Soc 
pages,  with  278  illustrations  in  the  text,  and  5  colored  plates.  Price, 
Cloth,  $3.50  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one  of  the 
very  best  English  text-books  on  the  subject." — Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical  Journal. 

WATER  AND  WATER  SUPPLIES.  By  JOHN  C.  THRESH,  D.  Sc., 
M.  B.,  D.  P.  H.,  Lecturer  on  Public  Health,  King's  College,  London; 
Editor  of  the  "Journal  of  State  Medicine,"  etc.  i2mo,  438  pages,  illus- 
trated. Handsomely  bound  in  Cloth,  with  gold  side  and  back  stamps 
Price,  $2.25  net. 


16  W.   B.   SAUNDERS'   ILLUSTRATED 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  SYDNEY  ROWLAND, 
B.  A.,  Camb.,  late  Scholar  of  Downing  College,  Cambridge,  and  Shuter 
Scholar  of  St.  Bartholomew's  Hospital,  London  ;  Special  Commissioner  to 
"British  Medical  Journal"  for  the  Investigation  of  the  Applications  of  the 
New  Photography  to  Medicine  and  Surgery.  A  series  of  collotype  illustra- 
tions, with  descriptive  text,  illustrating  the  applications  of  the  New  Photog- 
raphy to  Medicine  and  Surgery.  Price,  per  Part,  £1.00.  Parts  I.  to  III. 
now  ready. 

The  object  of  this  publication  is  to  put  on  record  in  permanent  form  some  of 
the  most  striking  applications  of  the  new  photography  to  the  needs  of  Medicine 
and  Surgery. 

The  progress  of  this  new  art  has  been  so  rapid  that,  although  Prof.  Rontgen's 
discovery  is  only  a  thing  of  yesterday,  it  has  already  taken  its  place  among  the 
approved  and  accepted  aids  to  diagnosis. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTICAL 
DISSECTION,  containing  "Hints  on  Dissection."  By  CHARLES  B. 
NANCREDE,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in-  the  Uni- 
versity of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price :  Extra  Cloth  (or  Oilcloth  for  the  dissection-room),  $2.00  net. 

No  pains  nor  expense  has  been  spared  to  make  this  work  the  most  exhaustive 
yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  published,  either  in 
America  or  in  Europe.  The  colored  plates  are  designed  to  aid  the  student  in 
dissecting  the  muscles,  arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been 
specially  drawn  and  engraved,  and  an  Appendix  added  containing  60  illustrations 
representing  the  structure  of  the  entire  human  skeleton,  the  whole  being  based 
on  the  eleventh  edition  of  Gray's  Anatomy. 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  STEVENS, 
A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College  of 
Philadelphia.  Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post  8vo,  512  pages.  Illustrated.  Price,  $2.50. 

FOURTH    EDITION,  REVISED    AND    ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them  that 
knowledge  which  is  absolutely  essential.  From  an  extended  experience  in  teach- 
ing, the  author  has  been  enabled,  by  classification,  to  group  allied  symptoms,  and 
by  the  elimination  of  theories  and  redundant  explanations  to  bring  within  a  com- 
paratively small  compass  a  complete  outline  of  the  practice  of  medicine. 

TEMPERATURE  CHART.  Prepared  by  D.  T.  LAINE,  M.  D.  Size 
8x  131^  inches.  Price,  per  pad  of  25  charts,  50  cents  net. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for  daily  amounts  of 
Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever. 


CATALOGUE   OF  MEDICAL    WORKS. 


MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS.     By 

A.  A.  STEVENS,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  Uni- 
versity of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.  445  pages.  Price,  Cloth,  $2.25. 

SECOND    EDITION,   REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections :  Physiological  Action  of  Drugs ; 
Drugs ;  Remedial  Measures  other  than  Drugs ;  Applied  Therapeutics ;  Incom- 
patibility in  Prescriptions ;  Table  of  Doses ;  Index  of  Drugs ;  and  Index  of  Dis- 
eases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Appli- 
cations and  Modes  of  Administration.  By  DAVID  CERNA,  M.D.,  PH.D., 
Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in  the  Univer- 
sity of  Pennsylvania.  Post  8vo,  253  pages.  Price,  $1.25. 

SECOND    EDITION,  RE- WRITTEN   AND    GREATLY    ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and  chem- 
ical formula. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  BY  WILLIAM 
M.  POWELL,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  convenient 
pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves  for  additions; 
with  an  Appendix  containing  Posological  Table,  Formulae  and  Doses  for 
Hypodermic  Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various  Dis- 
eases, Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia 
from  Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive 
Fevers,  Weights  and  Measures,  etc.  Third  edition,  revised  and  greatly 
enlarged.  Handsomely  bound  in  morocco,  with  side  index,  wallet,  and  flap. 
Price,  $1.75  net. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense  amount 
of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is  given  is 
unusually  reliable." — New  York  Medical  Record. 

SAUNDERS'  POCKET  MEDICAL  LEXICON;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  JOHN  M. 
KEATING,  M.  D.,  Editor  of  "Cyclopaedia  of  Diseases  of  Children,"  etc. ; 
Author  of  the  "New  Pronouncing  Dictionary  of  Medicine,"  and  HENRY 
HAMILTON,  Author  of  "A  New  Translation  of  Virgil's  ^Eneid  into  English 
Verse;"  Co- Author  of  a  "New  Pronouncing  Dictionary  of  Medicine.'* 
A  new  and  revised  edition.  321110,  282  pages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  $1.00. 

"Remarkably  accurate  in  terminology,  accentuation,  and  definition."— Journal  of  American 
Medical  Association. 


W.  B.  SAUNDERS"  ILLUSTRATED 


DISEASES  OF  WOMEN.  By  HENRY  J.  GARRIGUES,  A.  M.,  M.  D.,  Pro- 
fessor of  Obstetrics  in  the  New  York  Post-  Graduate  Medical  School  and  Hos- 
pital ;  Gynaecologist  to  St.  Mark's  Hospital,  and  to  the  German  Dispensary, 
etc.,  New  York  City.  One  octavo  volume  of  nearly  700  pages,  illustrated 
by  300  wood-cuts  and  colored  plates.  Prices:  Cloth,  $4.00  net;  Sheep, 
$5.00  net. 

A  PRACTICAL  work  on  gynaecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  knowledge 
of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by  the 
author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chapters  on 
Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based  upon  the 
large  hospital  and  private  practice  of  the  author.  The  text  is  elucidated  by  a 
large  number  of  illustrations  and  colored  plates,  many  of  them  being  original,  and 
forming  a  complete  atlas  for  studying  embryology  and  the  anatomy  of  the  female 
genitalia,  besides  exemplifying,  whenever  needed,  morbid  conditions,  instruments, 
apparatus,  and  operations. 

EXCERPT   OF   CONTENTS. 

Development  of  the  Female  Genitals.  —  Anatomy  of  the  Female  Pelvic  Organs.  —  Physiology.  — 
Puberty.  —  Menstruation  and  Ovulation.  —  Copulation.  —  Fecundation.  —  The  Climacteric.  —  Etiology 
in  General.  —  Examinations  in  General.  —  Treatment  in  General.  —  Abnormal  Menstruation  and  Me- 
trorrhagia.  —  Leucorrhea.  —  Diseases  of  the  Vulva.  —  Diseases  of  the  Perineum.  —  Diseases  of  the 
Vagina.  —  Diseases  of  the  Uterus.  —  Diseases  of  the  Fallopian  Tubes.  —  Diseases  of  the  Ovaries.  — 
Diseases  of  the  Pelvis.  —  Sterility. 

The  reception  accorded  to  this  -work  has  been  most  nattering.  In  the 
short  period  which  has  elapsed  since  its  issue,  it  has  been  adopted  and 
recommended  as  a  text-book  by  more  than  6O  of  the  Medical  Schools  and 
Universities  of  the  United  States  and  Canada. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning  and  great 
clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a  most  attractive  and 
instructive  form.  Young  practitioners,  to  whom  experienced  consultants  may  not  be  available,  will 
find  in  this  book  invaluable  counsel  and  help." 

THAD.  A.  REAMY,  M.  D.,  LL.D., 

Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio  ;   Gynecologist  to  the  Good 
Samaritan  and  to  the  Cincinnati  Hospitals. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THO- 
RAX. By  ARTHUR  M.  CORWIN,  A.  M.,  M.  D.,  Demonstrator  of  Physical 
Diagnosis  in  the  Rush  Medical  College,  Chicago  ;  Attending  Physician  to 
the  Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

This  book  was  originally  published  for  the  use  of  students,  but  its  rapid  absorp- 
tion by  the  practitioner  made  it  appear  that  a  wider  field  had  been  reached.  In 
this  edition  the  author  has  added  to  his  revision  of  the  text  a  section  setting  forth 
the  signs  found  in  each  of  the  diseases  of  the  chest,  thereby  increasing  its  value  to 
the  general  practitioner  for  post-graduate  study. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of  physical 
exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good  working  know- 
ledge of  the  subject."  —  Philadelphia  Polyclinic. 


CATALOGUE   OF  MEDICAL    WORKS.  19 


SYLLABUS    OF    OBSTETRICAL    LECTURES   in  the    Medical 

Department,  University  of  Pennsylvania.  By  RICHARD  C.  NORRIS, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsylvania. 
Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo.  Price,  Cloth, 
interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take 
pleasure  in  calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject 
thoroughly,  and  will  prove  invaluable  both  to  the  student  and  the  practitioner. 
The  author  has  introduced  a  number  of  valuable  hints  which  would  only  occur 
to  one  who  was  himself  an  experienced  teacher  of  obstetrics.  The  subject-matter 
is  clear,  forcible,  and  modern.  We  are  especially  pleased  with  the  portion  devoted 
to  the  practical  duties  of  the  accoucheur,  care  of  the  child,  etc.  The  paragraphs 
on  antiseptics  are  admirable ;  there  is  no  doubtful  tone  in  the  directions  given. 
No  details  are  regarded  as  unimportant ;  no  minor  matters  omitted.  We  venture 
to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which 
he  cannot  afford  to  despise." — Medical  Record. 

A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  LONG,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Virginia, 
etc.  Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  Text-Book  it  will  also  have  an  independent  value  as  an  aid  to  the  prac- 
titioner in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture-room, 
as  the  subject  is  presented  in  a  manner  systematic,  succinct,  and  practical. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "An  American  Text-Book 
of  Surgery."  By  NICHOLAS  SENN,  M.  D.,  PH.  D.,  Professor  of  Surgery  in 
Rush  Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.  Price,  $2.00. 

This  excellent  work  of  its  eminent  author,  himself  one  of  the  contributors  to 
"An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to  the 
advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not  only  the 
syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an  epitome  of, 
or  supplement  to  the  larger  work. 

AN    OPERATION    BLANK,  with    Lists    of  Instruments,    etc.    re 
quired   in  Various    Operations.     Prepared   by  W.  W.   KEEX,  M.   D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  College, 
Philadelphia.     Price   per   pad,    containing   Blanks   for   fifty   operations,    50 
cents  net. 

SECOND   EDITION,   REVISED  FORM. 

A  convenient  blank  (suitable  for  all  operations),  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed.  On  the  back  of  each  blank  is  a  list  of  instruments 
used — viz.  general  instruments,  etc.,  required  for  all  operations;  and  special  in- 
struments for  surgery  of  the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum, 
male  and  female  genito-urinary  organs,  the  bones,  etc.  The  whole  forming  a  neat 
pad,  arranged  for  hanging  on  the  wall  of  a  surgeon's  office  or  in  the  hospital 
operating-room. 


20 


W.  B.  SAUNDERS'  ILLUSTRATED 


LABORATORY  EXERCISES  IN  BOTANY.  By  EDSON  S.  BASTIN, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  with  87  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
•covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  The  illus- 
trations fully  elucidate  the  text,  and  the  complete  index  facilitates  reference. 


Trailing  Arbutus  (Epigea  repens) 
Specimen  Illustration. 


LABORATORY   GUIDE    FOR    THE    BACTERIOLOGIST.      By 

LANGDON  FROTHINGHAM,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veterinary 
Science,  Sheffield  Scientific  School,  Yale  University.  Illustrated.  Price. 
Cloth,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.  The  book  is  especially  intended  for  use  in  laboratory  work. 

OBSTETRIC    ACCIDENTS,    EMERGENCIES,    AND    OPERA- 
TIONS.    By  L.  CH.  BOISLINIERE,  M.  D.,  late  Emeritus  Professor  of  Ob- 
stetrics in  the  St.  Louis  Medical  College.     381  pages,  handsomely  illustrated. 
Price,  $2.00  net. 
"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 

opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.     He 

then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 

guiding  and  assisting  him  in  emergencies. >f 


CA  TALOGUE  OF  MEDICAL    WORKS. 


HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  JOHN  M. 
KEATING,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of  Phila- 
delphia; Vice-President  of  the  American  Poediatric  Society;  Ex- President 
of  the  Association  of  Life  Insurance  Medical  Directors.  Royal  8vo,  211 
pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by  Dr. 
McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate  the  text. 
Price,  in  Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a  sub- 
ject of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is  Part  II., 
which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four  representative 
companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected  by  the  directors  of 
the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these  alone  the  book  should  be 
at  the  right  hand  of  every  physician  interested  in  this  special  branch  of  medical  science." — The 
Medical  News,  Philadelphia. 

THE  CARE  OF  THE  BABY.  By  J.  P.  CROZER  GRIFFITH,  M.  D.,  Clftii- 
cal  Professor  of  Diseases  of  Children,  University  of  Pennsylvania ;  Physician 
to  the  Children's  Hospital,  Philadelphia,  etc.  392  pages,  with  67  illustrations 
in  the  text,  and  5  plates.  i2mo.  Price,  $1.50. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and  prac- 
titioners whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  master 
hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by  any  prac- 
titioners who  have  not  had  large  opportunities  for  observing  children." — American  Joiirnal  of 
Obstetrics,  July,  1895. 

"The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  .  There 
are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advantage." — Archives 
of  Pediatrics,  Aug.,  1895. 

"  No  better  book  of  its  kind  has  come  under  our  notice  for  some  time.  Although  intended 
primarily  for  mothers  and  nurses,  it  will  well  repay  perusal  by  medical  students." — Birmingham 
Medical  Review,  Oct.,  1895. 

"  This  is  one  of  the  best  works  of  its  kind  that  has  been  presented  to  the  people  for  many  a 
day." — Maryland  Medical  Journal,  Aug.  13,  1895. 

NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  ISABEL  ADAMS 
HAMPTON,  Graduate  of  the  New  York  Training  School  for  Xurses  attached  to 
Bellevue  Hospital;  Superintendent  of  Nurses,  and  Principal  of  the  Training 
School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md.  ;  late  Superin- 
tendent of  Nurses,  Illinois  Training  School  for  Nurses,  Chicago,  111.  In  one 
very  handsome  xamo  volume  of  484  pages,  profusely  illustrated.  Price, 
Cloth,  $2.00  net. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  compre- 
hensive and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suit- 
able alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  deside- 
ratum with  those  intrusted  with  the  management  of  hospitals  and  the  instruction 
of  nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduate  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick  and 
the  hygiene  of  the  sick-room. 


22  W.  B.  SAUNDERS'   ILLUSTRATED  CATALOGUE. 

NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing  Treat- 
ment,  containing  Definitions  of  the  Principal  Medical  and  Nursing  Terms 
and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Physiological  Names,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  Compiled  for  the  use  of  nurses.  By 
HONNOR  MORTEN,  Author  of  "How  to  Become  a  Nurse,"  "Sketches  of 
Hospital  Life,"  etc.  i6mo,  140  pages.  Price,  Cloth,  $1.00. 

This  little  volume  is  intended  merely  as  a  small  reference-book  which  can  be 
•  onsulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation  to  the 
i.iirse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up  larger 
and  fuller  works  on  the  subject. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  MRS.  ERNEST  HART, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  INTRODUCTION  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.'  Price, 
Cloth,  $1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  ...  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  .  .  .  .  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — Medical  Journal,  New  York. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND  IN 
DISEASE.  By  Louis  STARR,  M.  D.,  Editor  of  "An  American  Text- 
Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size),  per- 
forated and  neatly  bound  in  flexible  morocco.  Price,  $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life ; 
each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter 
directions  being  left  for  the  physician.  After  the  seventh  month,  modifications 
being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula  for  the  prepara- 
tion of  diluents  and  foods  are  appended. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  JEROME  B.  THOMAS, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings  County 
Hospital ;  Assistant  Bacteriologist,  Brooklyn  Health  Department.  Price, 
$1.50.  Send  for  sample  sheet. 

There  is  here  offered,  in  portable  form,  as  an  efficient  aid  to  the  better  practice 
of  Therapeutics,  a  collection  of  detachable  Diet  Lists  and  a  Sick-room  Dietary. 
It  meets  a  want,  for  the  busy  practitioner  has  but  little  time  to  write  out  Systems 
of  Diet  appropriate  to  his  patients,  or  to  describe  the  preparation  of  their  food. 
Compiled  from  the  most  modern  works  on  dietetics,  the  Dietary  offers  a  variety 
of  easily-digested  foods. 

"A  convenience  that  will  be  appreciated  by  the  physician." — Medical  Journal,  New  York. 

"  The  work  is  an  excellent  one,  and  ought  to  be  welcomed  by  physician,  patient,  and  nurse 
alike/' — Indian  Lancet,  Calcutta. 


Practical,  Exhaustive.  Authoritative. 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS. 

FOR 

STUDENTS  AND   PRACTITIONERS. 


MR.  SAUNDERS  is  pleased  to  announce  the  successful  issue  of  several  volumes 
of  his  NEW  AID  SERIES  OF  MANUALS,  which  have  received  the 
most  flattering  commendations  from  Students  and  Practitioners  and 
the  Press.  As  publisher  of  the  STANDARD  SERIES  OF  QUESTION  COMPENDS, 
and  through  intimate  relations  with  leading  members  of  the  medical  profession, 
Mr.  Saunders  has  been  enabled  to  study  progressively  the  essential  desiderata  in 
practical  "  self-helps  "  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "Question  Compends" 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgery,  each  subject  being 
compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without  the  intro- 
duction of  cases  and  foreign  subject-matter  which  so  largely  expand  ordinary  text- 
books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  new  series,  therefore,  will  form  an  admirable  col- 
lection of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in  reading 
and  in  comprehending  the  contents  of  "  recommended  "  works. 

Each  Manual  will  further  be  distinguished  by  the  beauty  of  the  new  type  ;  by 
the  qaality  of  the  paper  and  printing ;  by  the  copious  use  of  illustrations ;  by  the 
attractive  binding  in  cloth;  and  by  the  extremely  low  price  at  which 

they  will  be  sold. 

23 


Saunders  New  Aid  Series  of  Manual* 


0. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY,  by  JOSEPH  HOWABD  RAYMOND,  A.  M.,  M.  D.,  Professor  of  Physi- 
ology and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hos- 
pital ;  Director  of  Physiology  in  the  Hoagland  Laboratory ;  formerly  Lecturer  on 
Physiology  and  Hygiene  in  the  Brooklyn  Normal  School  for  Physical  Education; 
Ex- Vice- President  of  the  American  Public  Health  Association ;  Ex-Health  Commis- 
sioner, City  of  Brooklyn,  etc.  Illustrated.  $1.25  net 

SURGERY,  General  and  Operative,  by  JOHN  CHALMERS  DACOSTA,  M.  D.,  Demon- 
strator of  Surgery,  Jefferson  Medical  College,  Philadelphia;  Chief  Assistant  Sur- 
geon, Jefferson  Medical  College  Hospital ;  Surgical  Registrar,  Philadelphia  Hospital, 
etc.  188  illustrations  and  13  plates.  (Double  number.)  $2.50  net 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING,  by  E.  Q. 
THORNTON,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia. Illustrated.  Price,  cloth,  $1.25  net 

SURGICAL  ASEPSIS,  by  CARL  BECK,  M.  D.,  Surgeon  to  St  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.  Illustrated.  Price,  cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE,  by  HENRY  C.  CHAPMAN,  M.  D.,  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of 
Philadelphia;  Member  of  the  College  of  Physicians  of  Philadelphia,  of  the  Acade- 
my of  Natural  Sciences,  of  the  American  Philosophical  Society,  and  of  the  Zoologi- 
cal Society  of  Philadelphia.  Illustrated.  $1.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES,  by  JAMES  NEVINS  HYDE, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  FRANK  H.  MONTGOMERY, 
M.  D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases,  in  Rush  Medical 
College,  Chicago.  Profusely  Illustrated.  (Double  number.)  $2.50  net. 

PRACTICE  OF  MEDICINE,  by  GEORGE  ROE  LOCKWOOD,  M.  D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary ;  Instructor 
of  Physical  Diagnosis  of  the  Medical  Department  of  Columbia  College;  Attending 
Physician  to  the  Colored  Hospital;  Pathologist  to  the  French  Hospital;  Member 
of  the  New  York  Academy  of  Medicine,  of  the  Pathological  Society,  of  the  Clinical 
Society,  etc.  Illustrated.  (Double  number.)  $2.50  net. 

MANUAL  OF  ANATOMY,   by    IRVING  S.  HAYNES,  M.D.,  Adjunct  Professor  of 
Anatomy   and    Demonstrator  of    Anatomy,    Medical    Department   of  the   New   York 
University,  etc.     Beautifully  Illustrated.     (Double  number.)     Price,  $2.50  net. 

MANUAL  OF  OBSTETRICS,  by  W.  A.  NEWMAN  DORLAND,  M.  D.,  Asst.  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital ;  Member  of  Philadelphia  Obstetrical  Society,  etc. 
Profusely  illustrated.  (Double  number.)  Price,  $2.50  net. 

DISEASES  OF  WOMEN,  by  J.  BLAND  SUTTON,  F.  R.  C.  S.,  Asst.  Surgeon  to  Mid- 
dlesex Hospital,  and  Surgeon  to  Chelsea  Hospital,  London ;  and  ARTHUR  E.  GILES, 
M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S.  Edin.,  Asst.  Surgeon  to  Chelsea  Hospital,  London. 
436  pages,  handsomely  illustrated.  (Double  number.)  Price,  $2.50  net. 


VOLUMES   IN  PREPARATION. 

NOSE  AND  THROAT,  by  D.  BRADEN  KYLE,  M.D.,  Chief  Laryngologist  of  the  St 
Agnes  Hospital,  Philadelphia ;  Bacteriologist  of  the  Orthopaedic  Hospital  and 
Infirmary  for  Nervous  Diseases ;  Instructor  in  Clinical  Microscopy  and  Assistant 
Demonstrator  of  Pathology  in  the  Jefferson  Medical  College,  etc. 

NERVOUS  DISEASES,  by  CHARLES  W.  BURR,  M.  D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia  ;  Pathologist  to  the  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  close  intervals,  carefully-prepared  works  on 
various  subjects,  by  prominent  specialists. 

24 


SAUNDERS' QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form, 

THE  LATEST,  CHEAPEST,  AND  BEST  ILLUSTRATED  SERIES 
OF  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


Students  and  Practitioners  in  every  City  of  the  United  States 

and  Canada. 


THE  REASON   WHY 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  HELP;  they  are  the  leaders  in 
their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in  the  large  col- 
leges, know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations.  The  judgment 
exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen 
from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  become  Pro- 
fessors and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages,  profusely 
illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised  and 
enlarged  when  necessary,  many  of  them  being  in  their  fourth  and  fifth  editions. 

TO  SUM   UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of  them 
approach  the  "  Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  the  following  points 
of  excellence : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

***  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  over  for  List). 

25 


26  W.  B.  SAUNDERS  ILLUSTRATED 

Saunders'  Question-Compend  Series. 

&&~  Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


1.  ESSENTIALS    OF    PHYSIOLOGY.     3d  edition.     Illustrated.     Revised  and  enlarged. 

By  H.  A.  HARE,  M.  D.     (Price,  #1.00  net.) 

2.  ESSENTIALS  OF  SURGERY.     5th  edition,  with  an  Appendix  on  Antiseptic  Surgery. 

90  illustrations.     By  EDWARD  MARTIN,  M.  D. 

3.  ESSENTIALS  OF  ANATOMY.      5th  edition,  with  an  Appendix.      180  illustrations.     By 

CHARLES  B.  NANCREDE,  M.  D. 

4.  ESSENTIALS  OF  MEDICAL    CHEMISTRY,  ORGANIC  AND   INORGANIC. 

4th  edition,  revised,  with   an  Appendix.     By  LAWRENCE  WOLFF,  M.  D. 

5.  ESSENTIALS  OF    OBSTETRICS.     3d  edition,  revised  and  enlarged.     75  illustrations. 

By  W.  EASTERLY  ASHTON,  M.  D. 

6.  ESSENTIALS   OF   PATHOLOGY    AND    MORBID   ANATOMY.     6th   thousand. 

46  illustrations.     By  C.  E.  ARMAND  SEMPLE,  M.  D. 

7.  ESSENTIALS     OF    MATERIA     MEDICA,     THERAPEUTICS,    AND     PRE- 

SCRIPTION-WRITING.    4th  edition.     By  HENRY  MORRIS,  M.  D. 

8.  9.  ESSENTIALS    OF    PRACTICE    OF    MEDICINE.     By   HENRY    MORRIS,  M.  D. 

An  Appendix  on  URINE  EXAMINATION.  Illustrated.  By  LAWRENCE  WOLFF,  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authorities, 
by  WM.  M.  POWELL,  M.  D.  (Double  number,  price  £2.00.) 

10.  ESSENTIALS    OF    GYNAECOLOGY.      3d  edition,   revised.      With   62   illustrations. 

By  EDWIN  B.  CRAGIN,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     3d  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.  By  HENRY  W.  STELWAGON,  M.  D. 
(Price,  $1.00  net.) 

12.  ESSENTIALS    OF    MINOR    SURGERY,  BANDAGING,  AND    VENEREAL 

DISEASES.  2d  edition,  revised  and  enlarged.  78  illustrations.  By  EDWARD 
MARTIN,  M.  D. 

13.  ESSENTIALS    OF   LEGAL   MEDICINE,  TOXICOLOGY,    AND    HYGIENE. 

130  illustrations.     By  C.  E.  ARMAND  SEMPLE,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF  THE  EYE,  NOSE,  AND   THROAT.     124 

illustrations.  2d  edition,  revised.  By  EDWARD  JACKSON,  M.  D.,  and  E.  BALDWIN 
GLEASON,  M.  D. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.      2d    edition.       By  WILLIAM  M. 

POWELL,  M.  D. 

16.  ESSENTIALS    OF    EXAMINATION    OF    URINE.      Colored    "  VOGEL   SCALE," 

and  numerous  illustrations.     By  LAWRENCE  WOLFF,  M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS    OF   DIAGNOSIS.     By   S.  SoLis-CoHEN,  M.  D.,  and  A.  A.  ESHNER, 

M.  D.     55  illustrations,  some  in  colors.    (Price,  $1.50  net.) 

18.  ESSENTIALS   OF    PRACTICE   OF  PHARMACY.     By  L.  E.  SAYRE.     2d  edition, 

revised  and  enlarged. 

20.  ESSENTIALS   OF    BACTERIOLOGY.      3d  edition.      82   illustrations.      By   M.   V. 

BALL,  M.  D. 

21.  ESSENTIALS    OF    NERVOUS  DISEASES  AND  INSANITY.     48   illustrations. 

2d  edition,  revised.     By  JOHN  C.  SHAW,  M.  D. 

22.  ESSENTIALS    OF    MEDICAL    PHYSICS.     155    illustrations.     2d   edition,   revised- 

By  FRED  J.  BROCKWAY,  M.  D.     (Price,  $1.00  net.) 

23.  ESSENTIALS    OF  MEDICAL   ELECTRICITY.     65   illustrations.     By  DAVID   D. 

STEWART,  M.  D.,  and  EDWARD  S.  LAWRANCE,  M.  D. 

24.  ESSENTIALS    OF    DISEASES    OF   THE    EAR.     By  E.  B.  GLEASON,  M.  D.     89 

illustrations. 


CATALOGUE   OF  MEDICAL    WORKS.  27 


JUST  PUBLISHED. 

A  TEXT-BOOK  OF  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PHARMACOLOGY.  By  GEORGE  F.  BUTLER,  PH.  G.,  M.  D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians  and  Surgeons;  Chicago  ;  Professor  of  Materia  Medica  and  Thera- 
peutics, Northwestern  University,  Woman's  Medical  School,  etc.  8vo,  858 
pages.  Illustrated.  Prices :  Cloth,  $4.00  net ;  Sheep  or  Half- Morocco,  $5.00  net 

A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room.  The  arrangement  (embodying 
the  synthetic  classification  of  drugs  based  upon  therapeutic  affinities)  is  believed 
to  be  at  once  the  most  philosophical  and  rational,  as  well  as  that  best  calculated  to 
engage  the  interest  of  those  to  whom  the  academic  study  of  the  subject  is  wont  to 
offer  no  little  perplexity. 

Special  attention  has  been  given  to  the  Pharmaceutical  section,  which  is 
exceptionally  lucid  and  complete. 

LECTURES    ON    RENAL    AND    URINARY    DISEASES.       By 

ROBERT  SAUNDBY,  M.  D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the 
Hospital  for  Diseases  of  Women ;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  8vo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.  Price,  Cloth,  $2.50  net. 

In  these  Lectures,  which  are  a  re-issue  in  one  volume  of  the  author's  well- 
known  works  on  Bright s  Disease  and  Diabetes,  there  is  given,  within  a  modest 
compass,  a  review  of  the  present  state  of  knowledge  of  these  important  affections, 
with  such  additions  and  suggestions  as  have  resulted  from  the  author's  thirteen 
years'  clinical  and  pathological  study  of  the  subjects.  The  lectures  have  been 
carefully  revised  and  much  new  matter  added  to  them.  There  has  also  been  added 
a  section  dealing  with  "Miscellaneous  Affections  of  the  Kidney,"  making  the 
book  more  complete  as  a  work  of  reference. 

ELEMENTARY   BANDAGING   AND   SURGICAL   DRESSING, 

with  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.  By  WALTER  PYE,  F.  R.  C.  S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  So  illus- 
trations. Cloth,  flexible  covers.  Price,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft"  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which  treat 
of  the  management  in  the  first  instance  of  cases  of  emergency.  Within  its  own 
limits,  however,  the  book  is  complete,  and  it  is  hoped  that  it  will  prove  extremely 
useful  to  students  when  they  begin  their  work  in  the  wards  and  casualty  rooms, 
and  useful  also  to  surgical  nurses  and  dressers. 

"  The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 

"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 

"  One  of  the  most  useful  little  works  for  dressers  and  nurses.  The  author  truly  says  that  it  is  '  r 
very  little  book,'  but  it  is  large  in  usefulness." — Chemist  and  Druggist. 


JUST  ISSUED.  SOLD   BY  SUBSCRIPTION, 

ANOMALIES 

AND 

CURIOSITIES  OF  MEDICINE. 

BY 

GEORGE  M.   GOULD,   M.  D., 

AND 
WALTER  L.  PYLE,  M.  D. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors 
in  the  great  medical  libraries  of  the  United  States  and  Europe  in  col- 
lecting the  material  for  this  work.  Medical  literature  of  all  ages 
and  all  languages  has  been  carefully  searched,  as  a  glance  at  the 
Bibliographic  Index  will  show.  The  facts,  which  will  be  of  extreme 
value  to  the  author  and  lecturer,  have  been  arranged  and  anno- 
tated, and  full  reference  footnotes  given,  indicating  whence  they  have 
been  obtained. 

In  view  of  the  persistent  and  dominant  interest  in  the  anomalous 
and  curious,  a  thorough  and  systematic  collection  of  this  kind 
(the  first  of  which  the  authors  have  knowledge)  must  have  its  own 
peculiar  sphere  of  usefulness. 

As  a  complete  and  authoritative  Book  of  Reference  it  will  be 
of  value  not  only  to  members  of  the  medical  profession,  but  to  all 
persons  interested  in  general  scientific,  sociologic,  and  medico-legal 
topics ;  in  fact,  the  general  interest  of  the  subject  and  the  dearth  of 
any  complete  work  upon  it  make  this  volume  one  of  the  most 
important  literary  innovations  of  the  day. 

An  especially  valuable  feature  of  the  book  consists  of  the  Indexing. 
Besides  a  complete  and  comprehensive  General  Index,  containing 
numerous  cross-references  to  the  subjects  discussed,  and  the  names 
of  the  authors  of  the  more  important  reports,  there  is  a  convenient 
Bibliographic  Index  and  a  Table  of  Contents. 

The  plan  has  been  adopted  of  printing  the  topical  headings  in 
bold-face  type,  the  reader  being  thereby  enabled  to  tell  at  a  glance 
the  subject-matter  of  any  particular  paragraph  or  page. 

Illustrations  have  been  freely  employed  throughout  the  work, 
there  being  165  relief  cuts  and  130  half-tones  in  the  text,  and  12 
colored  and  half-tone  full- page  plates — a  total  of  over  320  separate 
figures. 

The  carefuf  rendering  of  the  text  and  references,  the  wealth  of  illus- 
trations, the  mechanical  skill  represented  in  the  typography,  the  print- 
ing, and  the  binding,  combine  to  make  this  book  one  of  the  most 
attractive  medical  publications  ever  issued. 


Handsome    Imperial  Octavo  Volume  of  968  Pages. 
PRICES:    Cloth,  $6.OO  net;    Half  Morocco,  $7.OO  net. 


JUST   ISSUED. 

PENROSE'S  DISEASES  OF  WOMEN. 

A  Text-Book  of  Diseases  of  Women.  By  CHARLES  B.  PENROSE,  M.  D.,  PH.D.,  Pro- 
fessor of  Gynecology,  University  of  Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Phil- 
adelphia. Octavo  volume  of  529  pages,  handsomely  illustrated.  Price,  $3.50  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  By  FRANK  B.  MALLORY,  A.  M.,  M.  D.,  Asst.  Professor  of 
Pathology,  Harvard  University  Medical  School;  and  JAMES  H.  WRIGHT,  A.M.,  M.  D., 
Instructor  in  Pathology,  Harvard  University  Medical  School.  Octavo  volume  of  396  pages, 
handsomely  illustrated. 

SENN'S  GENITO-URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito- Urinary  Organs,  Male  and  Female.  By  NICHOLAS 
SENN,  M.  D.,  PH.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College,  Chicago.  Handsome  octavo  volume  of  320  pages.  Illustrated. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  BLAND  SUTTON,  F.  R.  C.  S.,  Asst.  Surgeon  to  Middlesex 
Hospital,  and  Surgeon  to  Chelsea  Hospital,  London ;  and  ARTHUR  E.  GILES,  M.  D.,  B.  Sc. 
Lond.,  F.  R.  C.  S.  Edin.,  Asst.  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.  Price,  $2.50  net. 


IN  PREPARATION. 

ANDERS'  PRACTICE  OF  MEDICINE. 

A  Text-Book  of  the  Practice  of  Medicine.     By  JAMES  M.  ANDERS,  M.  D.,  PH.D., 

LL.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical 
College,  Philadelphia.  In  press. 

AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND  SKIN  DISEASES. 

Edited  by  L.  BOLTON  BANGS,  M.  D.,  Late  Professor  of  Genito-Urinary  and  Venereal  Dis- 
eases, New  York  Post-Graduate  Medical  School  and  Hospital,  and  WILLIAM  A.  HARD- 
AWAY,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical  College. 

AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAR,  NOSE,  AND 
THROAT. 

Edited   by  G.  E.  DE  SCHWEINITZ,   M.  D.,  Professor   of  Ophthalmology  in   the  Jefferson 
fMedical  College,  and  B.  ALEXANDER  RANDALL,  M.  D.,  Professor  of  Diseases  of  the  Ear 
in  the  University  of  Pennsylvania  and  in  the  Philadelphia  Polyclinic. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  MACDONALD,  M.  D.,  Graduate  of 
Medicine  of  the  University  of  Edinburgh ;  Licentiate  of  the  Royal  College  of  Surgeons, 
Edinburgh;  Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Minneapolis 
College  of  Physicians  and  Surgeons. 

HIRST'S  OBSTETRICS. 

A  Text-Book  of  Obstetrics.  By  BARTON  COOKE  HIRST,  M.  D.,  Professor  of  Obstet- 
rics, University  of  Pennsylvania. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.     By  JAMES  E.  MOORE,  M.  D.,  Professor  of 

Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of  Minnesota,  College 
of  Medicine  and  Surgery. 

HEISLER'S   EMBRYOLOGY. 

A  Text-Book  of  Embryology.  By  JOHN  C.  HEISLER,  M.  D.,  Prosector  to  the  Pro- 
fessor of  Anatomy,  Medical  Department  of  the  University  of  Pennsylvania. 


NOW  READY— VOLUMES  FOR   1896  AND  1897. 


SAUNDERS' 

American  Year-Book  of  Medicine  and  Surgery 

COLLECTED  AND  ARRANGED  BY  EMINENT  AMERICAN  SPECIALISTS  AND  TEACHERS, 

UNDER    THE    EDITORIAL    CHARGE    OF 

GEORGE   M.  GOULD,  M.  D. 


NOTWITHSTANDING  the  rapid  multiplication  of  medical  and  surgical  works, 
still  these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician, 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  well- 
known  principles  of  medical  science.  Mr.  Saunders  has  long  been  impressed  with 
this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  profession 
at  large,  as  indicated  by  advices  from  his  large  corps  of  canvassers. 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but 
most  practitioners  have  scant  access  to  this  almost  unlimited  source  of  informa- 
tion, and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the 
many  interesting  cases,  whose  study  would  doubtless  be  of  inestimable  value  in  his 
practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient  form 
an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 
cannot  but  command  his  highest  appreciation.     It  is   this  critical  and  judicial 
function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year-Book 
of  Medicine  and  Surgery." 

It  is  the  special  purpose  of  the  Editor,  whose  experience  peculiarly  qualifies 
him  for  the  preparation  of  this  work,  not  only  to  review  the  contributions 
to  American  journals,  but  also  the  methods  and  discoveries  reported  in  the 
leading  medical  journals  of  Europe,  thus  enlarging  the  survey  and  making  the 
work  characteristically  international.  These  reviews  will  not  simply  be  a  series 
of  undigested  abstracts  indiscriminately  run  together,  nor  will  they  be  retro- 
spective of  "news"  one  or  two  years  old,  but  the  treatment  presented  will  be 
synthetic  and  dogmatic,  and  will  include  only  what  is  new.  Moreover,  through 
expert  condensation  by  experienced  writers,  these  discussions  will  be 

Comprised  in  a  Single  Volume  of  about  1200  Pages. 

The  work  will  be  replete  with  original  and  selected  illustrations  skilfully- 
reproduced,  for  the  most  part,  in  Mr.  Saunders'  own  studios  established  for 
the  purpose,  thus  ensuring  accuracy  in  delineation,  affording  efficient  aids  to  a 
right  comprehension  of  the  text,  and  adding  to  the  attractiveness  of  the  volume. 


Prices :  Cloth,  $6.50  net ;  Half  Morocco,  $7.50  net. 

W.  B.  SAUNDERS,  Publisher, 

925  "Walnut  Street,  Philadelphia^ 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


1|ft» 


A  000  500  754  7 


WP100 


1897 
Garrigues,  Henry  J 

A  text-book  of  the  diseases   of 
wor  en4 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


